Razones para Terminar La Terapia PDF

REASONS FOR TERMINATING PSYCHOTHERAPY: CLIENT AND THERAPIST
PERSPECTIVES
Robin Westmacott
Dissertation submitted to the
Faculty of Graduate and Postdoctoral Studies
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
in
Clinical Psychology
University of Ottawa
Ottawa, Ontario
2011
© Robin Westmacott, Ottawa, Canada, 2011

Library and Archives Bibliothèque et
Canada Archives Canada
Published Heritage Direction du
Branch Patrimoine de l'édition
395 Wellington Street 395, rue Wellington

Ottawa ON K1A 0N4 Ottawa ON K1A 0N4
Canada Canada
Your file Votre référence
ISBN: 978-0-494-98340-9
Our file Notre référence

ISBN: 978-0-494-98340-9
NOTICE: AVIS:
The author has granted a non- L'auteur a accordé une licence non exclusive
exclusive license allowing Library and permettant à la Bibliothèque et Archives
Archives Canada to reproduce, Canada de reproduire, publier, archiver,
publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public
communicate to the public by par télécommunication ou par l'Internet, prêter,
telecommunication or on the Internet, distribuer et vendre des thèses partout dans le
loan, distrbute and sell theses monde, à des fins commerciales ou autres, sur
worldwide, for commercial or non- support microforme, papier, électronique et/ou
commercial purposes, in microform, autres formats.
paper, electronic and/or any other
formats.
The author retains copyright L'auteur conserve la propriété du droit d'auteur

ownership and moral rights in this et des droits moraux qui protege cette thèse. Ni
thesis. Neither the thesis nor la thèse ni des extraits substantiels de celle-ci
substantial extracts from it may be ne doivent être imprimés ou autrement
printed or otherwise reproduced reproduits sans son autorisation.
without the author's permission.
In compliance with the Canadian Conformément à la loi canadienne sur la

Privacy Act some supporting forms protection de la vie privée, quelques
may have been removed from this formulaires secondaires ont été enlevés de
thesis. cette thèse.
While these forms may be included Bien que ces formulaires aient inclus dans
in the document page count, their la pagination, il n'y aura aucun contenu
removal does not represent any loss manquant.
of content from the thesis.
REASONS FOR TERMINATION ii
Abstract
Given the high prevalence of client unilateral termination from psychotherapeutic services,
elucidating client reasons for ending therapy is an important activity for researchers. Three
studies were designed to shed light on reasons for both premature and appropriate
termination from the perspective of adult clients and therapists: 1) In Study 1, I examined
data from the Canadian Community Health Survey, Cycle 1.2, to establish base rates of
client reasons for psychotherapy termination in Canada, along with their demographic and
clinical correlates, 2) In Study 2, I used training clinic data to examine client and therapist
perspectives of reasons for termination, working alliance, and barriers to treatment
participation in mutual versus unilateral terminators, and 3) In Study 3, I collected data from
Canadian clinical psychologists to examine their perspectives of client reasons for early
versus later termination, and their use of engagement strategies to reduce client-initiated
unilateral termination. In Study 1, 43.1 percent of respondents reported terminating therapy
for reasons other than feeling better or completing treatment. In general, individuals with low
income and diagnosable mental disorders had significantly increased odds of premature
termination. Study 2 revealed that when clients made unilateral decisions to end therapy,
therapists were only partially aware of either the extent of clients’ perceptions of their
success in therapy or with their dissatisfaction with therapy. Although working alliance and
barriers to treatment participation were rated as lower in the context of unilateral termination
by both clients and therapists than in the context of mutual decisions to terminate therapy, all
clients, in general, rated the early alliance and barriers to treatment as higher than did their
therapists. In Study 3 psychologists assigned differential importance to reasons for
termination depending on whether termination was before versus after the third session.
Theoretical orientation (CBT versus other) did not influence views of reasons for
REASONS FOR TERMINATION iii
termination, but influenced use of some engagement strategies. Results are discussed in
terms of research and clinical implications.

REASONS FOR TERMINATION iv
Statement of Co-Authorship
The three manuscripts included in this dissertation were prepared in collaboration with my
dissertation supervisor. I was the primary author and Dr. John Hunsley was the secondary
author for the first manuscript, entitled “Reasons for terminating psychotherapy: A general
population study” (Chapter Two), and the third manuscript, entitled “Psychologists’
Perspectives on Therapy Termination and the Use of Therapy Engagement Strategies”
(Chapter Four). For the second manuscript, “Client and therapist views of contextual factors
related to termination from psychotherapy: A comparison between unilateral and mutual
terminators” (Chapter Three), I was the primary author, Dr. John Hunsley was the second
author, and Drs. Marlene Best, Orly Rumstein-McKean, and Dwayne Schindler were also
included as authors. Drs. Best and Rumstein-McKean collected the data for the study, and
Dr. Dwayne Schindler provided statistical consultation. As the primary author on all
manuscripts, I was responsible for conceptualization of the research question and methods,
planning and execution of statistical analyses, and preparation of manuscripts. Dr. Hunsley
provided guidance and assistance in all aspects of the project, especially in the refinement of
study hypotheses, and editing of manuscripts.

REASONS FOR TERMINATION v
Acknowledgements
I would like to thank my supervisor, Dr. John Hunsley, for his steady support and
conscientiousness, and for fostering a skeptical approach to learning that has reached beyond
academia. I continue to look for and question the evidence. I have also benefitted from his
encouraging and modeling a sustainable approach to work-life balance. My committee
members, Drs. Catherine Lee, John Lyons, George Tasca, and external examiner Dr. Henny
Westra, facilitated a stimulating, productive, and enjoyable learning experience throughout
the defense process and deserve many thanks.
Dear friends have shared in the privilege of pursuing doctoral studies in psychology.
Special thanks are owed to my girlfriends within our discipline for the best five years so far,
particularly Natalie Jones, Jennifer Metcalf, and Lindsay Rosval for in vivo support and
countless study dates. I thank Norel Tucker and Lindsay Tallon for reliably enriching
hiatuses, and I thank Katherine Rogozinski and Jennifer Swan for their steadfast love and
wise counsel over these many years. I have appreciated the gentle and kind presence of
Salmeh Bani-Sadr this last year, and for helping me prepare for the defense.
I thank my partner, Rob Reid, whose love, flexibility, and remarkable pursuits have
broadened the scope and quality of these last important years of my graduate school journey.
Finally, I thank my family, most of all my mother and late father, who have provided the
most secure of bases from which to explore the world with curiosity and delight. My
graduate education has facilitated a keen awareness of the powerful protection their love has
bestowed.
REASONS FOR TERMINATION vi
Table of Contents
Abstract……………………………………………………………………………………… ii
Statement of Co-Authorship ....................................................................................................iv
Acknowledgements ...................................................................................................................v
List of Tables.......................................................................................................................... xii
CHAPTER 1..............................................................................................................................1
Reasons for Terminating Psychotherapy: Client and Therapist Perspectives...........................1
Prevalence of Premature Termination...................................................................................1
Correlates of Unilateral Termination ....................................................................................3
Client Expectations ...............................................................................................................5
Client Reasons for Termination ............................................................................................7
Working Alliance ..................................................................................................................9
Barriers to Treatment Participation .....................................................................................12
Concordance between Client and Therapist Perspectives on Termination .........................13
Reasons for Early versus Later Unilateral Termination......................................................18
Therapists Use of Engagement Strategies to Foster Mutual Decisions to End Therapy ....24
Therapist Use of Engagement Strategies in Routine Practice: Impact of Theoretical
Orientation...........................................................................................................................31
Summary .............................................................................................................................31
Overview of Studies and Hypotheses .................................................................................32
CHAPTER 2............................................................................................................................37
REASONS FOR TERMINATION vii
Reasons for Terminating Psychotherapy: A General Population Study .................................37
Abstract ...................................................................................................................................38
The Present Study ...............................................................................................................42
Methods...................................................................................................................................43
Participants and Procedure ..................................................................................................43
Measures .............................................................................................................................46
Results .....................................................................................................................................47
Reasons for Termination: Self-Reported Reasons for Termination....................................47
Odds of Selecting Reasons for Termination According to Demographic Variables, Mental
Disorder Diagnoses, and Mental Health Care Provider ......................................................48
Discussion ...............................................................................................................................52
References ...............................................................................................................................57
CHAPTER 3............................................................................................................................65
Client and Therapist Views of Contextual Factors Related to Termination from
Psychotherapy: ........................................................................................................................65
A Comparison between Unilateral and Mutual Terminators ..................................................65
Abstract ...................................................................................................................................66
Reasons for Termination .....................................................................................................69
Therapeutic Alliance ...........................................................................................................72
Barriers to Treatment Participation .....................................................................................73
The Present Study and Hypotheses .....................................................................................74

REASONS FOR TERMINATION viii
Method ....................................................................................................................................75
Participants..........................................................................................................................75
Measures .............................................................................................................................78
Procedure.............................................................................................................................82
Results .....................................................................................................................................82
Preliminary Analyses ..........................................................................................................82
Mutual vs. Unilateral Terminators: Reasons for Termination. Hypothesis 1a ...................84
Congruence between Client and Therapist Views on Reasons for Termination. Hypothesis
2a .........................................................................................................................................86
Congruence Between Client and Therapist Views on the Quality of the Working Alliance.
Hypotheses 1b and 2b .........................................................................................................88
Congruence Between Client and Therapist Views on Barriers to Treatment Participation.
Hypotheses 1c and 2c..........................................................................................................88
Discussion ...............................................................................................................................89
References ...............................................................................................................................95
CHAPTER 4..........................................................................................................................108
Psychologists’ Perspectives on Therapy Termination and the Use of Therapy Engagement
Strategies ...............................................................................................................................108
Abstract .................................................................................................................................109
Reasons for Early versus Later Unilateral Termination May Differ.................................111
Therapists Perspectives of Client Reasons for Termination .............................................112
Therapist Behaviors that Foster Mutual Decisions to End Psychotherapy .......................115

REASONS FOR TERMINATION ix
The Present Study and Hypotheses ...................................................................................116
Method ..................................................................................................................................118
Participants........................................................................................................................118
Procedure...........................................................................................................................119
Measures ...........................................................................................................................121
Results ...................................................................................................................................122
Proportions of Clients who Terminated at Different Points in Therapy ...........................123
Perspectives of Reasons for Termination Within Client Groups ......................................124
Psychologists’ Use of Engagement Strategies ..................................................................125
Perspectives of Reasons for Termination (Hypotheses 1 and 2).......................................126
Perspectives of Reasons for Termination: Impact of Theoretical Orientation (Hypothesis
3) .......................................................................................................................................128
Theoretical Orientation and Use of Engagement Strategies (Hypothesis 4).....................129
Discussion .............................................................................................................................130
Psychologists Perspectives of Clients’ Reasons for Termination .....................................131
Theoretical Orientation .....................................................................................................134
Use of Engagement Strategies ..........................................................................................134
References .............................................................................................................................139
CHAPTER 5..........................................................................................................................152
General Discussion................................................................................................................152
Introduction .......................................................................................................................152
Study 1: Reasons for Terminating Psychotherapy: A General Population Study.............152

REASONS FOR TERMINATION x
Study 2: Client and Therapist Views of Contextual Factors Related to Termination from
Psychotherapy: A Comparison between Unilateral and Mutual Terminators ..................157
Study 3: Psychologists’ Perspectives on Therapy Termination and the Use of Therapy
Engagement Strategies ......................................................................................................161
Research Implications .......................................................................................................167
Clinical Implications .........................................................................................................175
Conclusion.........................................................................................................................181
References .............................................................................................................................183
Appendix A: Study 2 Client Demographic Information .......................................................210
Appendix B: Study 2 Symptom Checklist - 10 (SCL-10).....................................................212
Appendix C: Study 2 Working Alliance InventoryBClient Form ........................................213
Appendix D: Study 2 Working Alliance InventoryBClinician Form ...................................214
Appendix E: Study 2 Global Assessment of Functioning (GAF) Scale ...............................215
Appendix F: Study 2 Barriers to Treatment Participation Scale - Client..............................216
Appendix G: Study 2 Termination Questions for the Client.................................................218
Appendix H: Study 2 Reasons for Termination – Client ......................................................219
Appendix I: Study 2 Barriers to Treatment Participation Scale - Therapist .........................220
Appendix J: Study 2 Termination Questions for the Clinician .............................................222
Appendix K: Study 2 Reasons for Termination – Therapist.................................................223
Appendix L: Study 3 Email List Recruitment Script ............................................................224

REASONS FOR TERMINATION xi
Appendix M: Study 3 CPA Recruit Research Participants Portal Script..............................225
Appendix N: Study 3 Informed Consent...............................................................................226
Appendix O: Study 3 Survey ................................................................................................228
Appendix P: Examination of Therapist Effects in Study 2 ...................................................234

REASONS FOR TERMINATION xii
List of Tables
Table 1: Studies of Client Reasons for Termination ...............................................................36!
Table 2:Endorsement of Reasons for Termination (N = 973).................................................62!
Table 3: Demographics of Participants Included in Inferential Analyses (N = 693). .............63!
Table 4: Means and Standard Deviations of Client and Therapist Ratings of the Importance
of Termination Reasons. .......................................................................................................105!
Table 5: Difference Scores and Standard Deviations (Client Importance Ratings Minus
Therapist Importance Ratings) of Reasons for Termination.................................................107!
Table 6: Psychologists’ Perspectives of the Importance of Reasons for Termination for
Clients Who Unilaterally Terminated Before the Third Session, After the Third Session, or
Mutually Terminated (Mean, Standard Deviation, and Proportion of Psychologists Reporting
the Reason as Important or Very Important to Clients’ Termination Decisions) .................149!
Table 7: Psychologists’ Use of Engagement Strategies: A Comparison Between
Psychologists with a CBT versus Other Orientation.............................................................151!
Table 8: Therapist Effects (Intraclass Correlation Coefficient, !I) and Adjusted Type I Error
Rate (p-value) for Each Dependent Variable ........................................................................236!

REASONS FOR TERMINATION 1
CHAPTER 1
Reasons for Terminating Psychotherapy: Client and Therapist Perspectives
For decades, clients’ ending psychotherapy prematurely has been a concern for
clinicians and a focus for researchers (e.g., Baekland & Lundwall, 1975; Persons, Burns, &
Perloff, 1988). Meta-analytic evidence, based on the findings of 125 studies, indicates that
nearly 50% of clients terminate psychotherapy before having completed the full course of
recommended services (Wierzbicki & Pekarik, 1993). Many clients discontinue before they
are able to fully benefit from psychotherapeutic services (Hansen, Lambert, & Forman, 2002;
Hunt & Andrews, 1992; Kazdin, Mazurick, & Siegel, 1994; Phillips, 1987). Elucidating the
factors that influence why clients leave before they have fully benefitted is an important
activity for researchers. One avenue for understanding why clients leave is to examine their
reasons for doing so. In this dissertation, my primary objective is to shed light on reasons for
both premature and appropriate termination from the perspective of adult clients and
therapists, in three separate studies: 1) a population study of client reasons for termination of
services across mental health care providers and settings, 2) a training clinic study comparing
client and therapist perspectives of reasons for termination and related contextual variables,
and 3) a survey of psychologists’ perspectives of client reasons for termination at different
points in therapy, as well as psychologists’ actions to engage and retain clients in therapy. In
this general introduction I outline the prevalence and correlates of premature termination
from therapy, the methods by which premature termination has been studied and the
resulting findings, and the importance of examining clients’ and therapists’ perspectives of
reasons for termination. I will also outline studies that have examined therapists’ actions to
engage and retain clients in therapy.
Prevalence of Premature Termination

Hunsley and Lee (2007) comprehensively reviewed effectiveness studies of evidence-
based treatments, and found that over half the reported studies had completion rates greater
than 75%, which is substantially higher than the rates of around half of participants
completing therapy reported by Wierzbicki and Pekarik (1993) in their meta-analysis.
Despite these encouraging steps forward with respect to evidence-based treatments,
completion rates in routine practice continue to remain much lower. Hansen, Lambert, and
Forman (2002) conducted a large, multi-site, multi-treatment review of 6,072 clients in
routine mental health practice and found that the mean number of sessions completed was
4.3. After this brief exposure to therapy, the treatment site exhibiting the most successful
clients had fewer than 10% of its clients recover, and fewer than 25% achieved any
improvement. Indeed, dose-response studies generally indicate that between 13 and 18
sessions of therapy are necessary for clinically significant change in psychiatric symptoms,
across various treatments and client diagnoses (Hansen et al, 2002). Results of the Hansen et
al. study demonstrate that five decades of research on premature termination of
psychotherapy has failed to result in reduced rates of client dropout in routine practice.
Furthermore, premature termination clearly has consequences for the effectiveness of therapy
(Barrett, Chua, Crits-Cristoph, Gibbons, & Thompson, 2008; Swift, Callahan, & Levine,
2009).
Premature termination has been defined a number of ways, including nonattendance
after the intake assessment (Longo, Lent, & Brown, 1992), nonattendance of two consecutive
sessions (Kolb, Beutler, Davis, Crago, & Shanfield, 1985), nonattendance at the last
scheduled session (Hatchett, Han, & Cooker, 2002), client termination of therapy within a
particular time period (Frayne, 1992), and making a unilateral decision to end treatment
without agreement of the therapist (Pekarik, 1992; Richmond, 1992; Tutin, 1987; Wierzbicki
& Pekarik, 1993). Pekarik (1985b) suggested that the client’s unilateral decision to terminate
best captures the construct of premature termination. This approach differentiates clients who
unilaterally terminate from clients who make mutual decisions with their therapists to end
treatment. It also avoids the problem of defining premature termination as the failure to
complete a prescribed number of sessions, as some clients achieve their goals prior to the end
of a set number of sessions (Barkham et al., 2006). Defining premature termination
according to the type of decision addresses the problem of appropriately classifying clients
who meet their treatment goals with few therapy sessions as well as clients who may remain
in therapy for a longer period of time, but leave before their goals have been reached. Since
Pekarik’s recommendation, most researchers have used this operationalization (e.g.,
Callahan, Aubuchon-Endsley, Borja, & Swift, 2009; Chisolm, Crowther, & Ben-Porath,
1997; Keijsers, Kampman, & Hoogduin, 2001; Richmond, 1992; Smith, Subich, & Kalodner,
1995; Tryon & Kane, 1993). Accordingly, Pekarik’s operationalization of unilateral
termination will be used throughout the dissertation.
Correlates of Unilateral Termination
In order to intervene to prevent client unilateral termination, we need to better
understand why clients leave before completing treatment. Most research in this area has
examined who leaves, focusing primarily on demographic variables. Severity of presenting
problems and diagnoses have also been examined in a limited number of studies. Results of
studies examining diagnoses have been inconsistent (e.g., Greenspan & Mann Kulish, 1985;
Hoffman, 1985), as have those for problem severity. For example, Thormählen, Weinryb,
Norén, Vinnars, and Bagedåhl-Strindlund (2003) examined predictors of unilateral
termination from supportive-expressive therapy for personality disorder (n = 80) and found
that clients with more severe diagnoses and more complex diagnostic pictures were more
likely to unilaterally terminate. In contrast, Edlund et al. (2002), using data from the United
States National Comorbidity Survey and the Mental Health Supplement to the Ontario
Health Survey, found no significant effect of diagnosis (DSM-III-R) on dropout rate.
Age and gender. Although several researchers failed to find reliable associations
between unilateral termination and client age and gender (e.g., Cartwright, 1955; Craig &
Huffine, 1976; Dubrin & Zastowny, 1988; Frank, Gliedman, Imber, Nash, & Stone, 1957;
Rubenstein & Lorr, 1956; Sledge, Moras, Hartley, & Levine, 1990), the meta-analytic results
of Wierzbicki and Pekarik (1993) indicated that younger clients were more likely to
prematurely terminate (mean d = .34). Three more recent studies also found that younger
clients are more likely to unilaterally terminate than are their older counterparts. Smith,
Koenigsberg, Yeomans, Clarkin, and Selzer (1995) found that younger age was associated
with higher rates of unilateral termination in treatment for individuals with borderline
personality disorder. Thormählen et al. (2003) found a similar pattern for individuals with
treated for personality disorder. Edlund et al. (2002) found, in a population-based sample of
1,261 individuals that younger age (15 – 24 years) was associated with higher odds of drop
out. No associations with gender were found in more recent studies (Edlund et al.;
Wierzbicki & Pekarik).
Ethnicity. Researchers have consistently found that unilateral termination is associated
with non-White ethnicity (Greenspan & Kulish, 1985; Sue, Fujino, Hu, Takeuchi, & Zane,
1991; Sue, McKinney, Allen, & Hall, 1974; Vail, 1978; Wierzbicki & Pekarik, 1993).
Across 21 studies, Wierzbicki and Pekarik (1993) found that increased risk for premature
termination was significantly associated with African–American (and other minority) race (d
= .23; SD = .34). Non-white ethnicity and socioeconomic disadvantage tend to be correlated
(Garfield, 1994), however, more recent research suggests that the association between non-
White ethnicity, socioeconomic disadvantage, and unilateral termination reflects an
interaction of client-therapist differences in culture, attitudes, and experiences (e.g., Illovsky,
2003). In line with this, researchers attempting to maximize perspective convergence by
matching therapist-client ethnicity and language reported an increased number of sessions
attended in a sample of 1,746 Asian clients in several Community Mental Health Centres
(CMHCs; Flaskerud & Liu, 1991). However, Hill, Koocher, and Norcross (2005), in their
review of client-therapist ethnic matching, concluded that insufficient research has been
conducted to uniformly recommend this as a way to improve treatment outcome.
Socioeconomic status (SES). Consistent associations have also been found between
unilateral termination and socioeconomic disadvantage (Baekland & Lundwall, 1975;
Garfield, 1994; Wierzbicki & Pekarik, 1993; Williams, Ketring, & Salts, 2005). In their
meta-analysis, Wierzbicki and Pekarik found that socioeconomic status (d = .37, SD = .27,
across 30 studies) and education (d = .28, SD = .44, across 22 studies) were significantly
associated with premature termination. Researchers and clinicians have historically attributed
this phenomenon to socioeconomic status-related educational disadvantages resulting in
reduced psychological mindedness, verbal skills, and lower capacities for abstract thinking,
all of which are fundamental requirements of any therapeutic approach (Reis & Brown,
1999). No empirical evidence has supported these assumptions; however, researchers have
found that the association between low SES and dropout are significantly attenuated when
client expectations for treatment duration are considered (Pekarik, 1991; Pekarik &
Stephenson, 1988; Pekarik & Wierzbicki, 1986).
Client Expectations
Client expectations, both for the effectiveness of treatment and the process of
treatment, have been shown to influence posttreatment outcomes. Constantino, Arnkoff,

Glass, Ametrano, and Smith (2011) conducted a meta-analysis of the effects of pretherapy or
early-therapy client outcome expectations on posttreatment outcomes (N = 8,016 clients, 46
independent samples). The overall weighted effect size was d = .24, p<.001, indicating a
small effect of outcome expectations on positive treatment outcomes. Fewer studies have
specifically examined expectations and unilateral termination. Gunzburger, Henggeler, and
Watson (1985) prospectively studied 30 therapy completers versus 15 unilateral terminators
(clients who terminated before the 4th session) at a training clinic. Client expectations, and
whether their expectations were met, were assessed before and after the first session.
Although the pre-session expectations of unilateral terminators did not differ from those of
continuers, the unilateral terminators were less likely to report that the first session generally
fulfilled their expectations and were less likely to rate the session as helpful. These findings
indicated that clients who terminated might have been well on their way to making unilateral
decisions to leave by the end of the initial session. The authors were at a loss to explain
these findings given that unilateral terminators did not differ from continuers in their
perceptions of therapist empathy, warmth, or genuineness. Moreover, based on observational
data, there were no significant differences in client-therapist interaction during the first 15
minutes of the session. Unilateral terminators rated themselves as improving to the same
extent as continuers did, however, therapists did not recognize this improvement to the same
degree as they did for continuers. This study was quite underpowered, so it is difficult to
interpret null findings.
Other researchers have also found significant associations between unmet expectations
and unilateral termination. Elkin et al. (1999), using data from the Treatment of Depression
Collaborative Research Program, examined client predictions about the types of therapy
strategies they believed would be helpful. Clients whose treatment assignment matched what
they thought would be helpful were more likely to continue beyond 4 sessions than clients
who received a treatment that was not congruent with their beliefs. These research findings
highlight the importance of examining the effects of contextual factors in psychotherapy,
such as client expectations, on both outcome and unilateral termination.
Client Reasons for Termination
One way to examine factors relevant to unilateral termination is to ask clients why
they terminated services. As outlined in Table 1, several clinic-based studies have
investigated clients’ reasons for terminating psychotherapy (Bados, Balaguer, & Saldana,
2007; Hunsley, Aubry, Vestervelt, & Vito, 1999; Hynan, 1990; Pekarik, 1983, 1992; Renk &
Dinger, 2002; Roe, Dekel, Harel, & Fennig, 2006; Todd, Deane, & Bragdon, 2003). Broadly,
reasons generally reflect one of three main themes: a) goal attainment or improvement in
therapy, b) therapist or therapy-centered reasons, such as perceptions of therapist
incompetence or dislike of therapist or therapy, and c) circumstantial barriers, such as lack of
money or scheduling conflicts. One of the most frequent reasons clients provide is that they
ended treatment due to satisfaction with the gains they had made. Across studies, the
percentage of clients ending treatment early because they had achieved their goals ranged
from 14% (Todd et al., 2003) to 45.5% (Roe et al., 2006). Researchers have also found that
many clients decide to end treatment because of dissatisfaction with the therapy or the
therapist. Across studies, the range of clients ending treatment early for dissatisfaction
reasons is from 8% (Todd et al., 2003) to 34% (Hunsley et al., 1999). Finally, many clients
also cite circumstantial barriers as factors in ending treatment early. Reasons such as
difficulties with scheduling, difficulties making child care arrangements, and financial
barriers have been given by 8.5% (Hunsley et al., 1999) to 54.6% (Roe et al., 2006) of
clients.
Some researchers have examined reasons for termination exclusively among those
who were viewed by therapists as unilaterally terminating therapy. Pekarik (1992), for
example, examined reasons for unilateral termination in clients at a public mental health
clinic. Of 49 clients contacted by researchers, 39% indicated that they unilaterally terminated
because their problem was solved or improved, 35% indicated circumstantial barriers, and
26% cited dissatisfaction with therapy or therapist. In a training clinic setting, Bados et al.
(2007) surveyed 60 clients out of 89 who unilaterally terminated therapy from their clinic. Of
the 60 clients, 46.7% dropped out due to low motivation or dissatisfaction with treatment or
therapist, 40% because of circumstantial barriers (transportation problems, scheduling,
illness, etc.), and 13.3% because they believed they had improved.
These studies provided invaluable information regarding common reasons given by
clients for ending psychotherapy. Although similar themes emerge in clients’ reasons across
these studies, the percentage of clients reporting these reasons varies greatly from study to
study. With so little systematic research in this area, it is impossible to determine whether
this variability is due to differences in measurement, sampling strategies, or unique aspects
of the settings in which the clients received services. I designed Study 1 to contribute to the
literature by examining clients’ self-reported reasons for ending psychotherapy across
various settings, client problems, and service providers. Using a large, representative,
Canadian community sample, client reasons for termination were examined, along with the
demographic (age, gender, and income) and clinical (mental disorder caseness)
characteristics of clients who selected them. A second study goal was to examine the
influence of these demographic variables, mental disorder caseness, and type of mental
health care provider on client odds of selecting each reason for termination. Based on
previously outlined findings in the literature, I expected that low income, younger age, and
meeting caseness criteria for mental disorders (anxiety disorder, mood disorder, or substance
dependence) would decrease the odds of selecting feeling better or having completed a full
course of treatment as a reason for termination. I also expected that these variables would
increase the odds of selecting other termination reasons (other than feeling better or
completing the recommended treatment).
Working Alliance
Another factor often examined in the psychotherapy research literature is the working
alliance. Working alliance is a widely studied and broadly conceptualized construct,
however, most theoretical definitions of the working alliance have three themes in common:
a) the collaborative nature of the relationship, b) the affective bond between client and
therapist, and c) client-therapist agreement on therapy goals and tasks (e.g., Bordin, 1979;
Horvath & Symonds, 1991). Perhaps the most consistent and durable finding in the
psychotherapy research literature is that a strong working alliance predicts treatment
outcome (e.g., Horvath & Symonds, 1991; Horvath, Del Re, Flückiger, & Symonds, 2011;
Martin, Garske, & Davis, 2000; Weerasekera, Linder, Greenberg, & Watson, 2001),
accounting for approximately 5% of the variability in outcome (e.g., Castonguay et al., 1996;
Siqueland et al., 2000). Martin et al. (2000) conducted a meta-analytic study of the working
alliance and therapy outcome. They found an overall weighted alliance-outcome correlation
of .22, which they deemed a moderate relation (n = 68 studies, SD = .12). Martin et al. failed
to find any significant moderators of the alliance-outcome relationship (e.g., type of outcome
measure, type of outcome rater, time of alliance assessment, type of alliance rater, type of
treatment, publication status). More recently, Horvath et al. (2011) conducted a similar meta-
analysis and found a correlation of .28 (k = 190 studies), also finding that alliance measure,
rater, time of assessment, type of treatment, and publication source failed to significantly
moderate the alliance-outcome relationship.
A poor working alliance between client and therapist is predictive of unilateral
termination (Johansson & Eklund, 2005; Saatsi, Hardy, & Cahill, 2007; Saltzman, Luetgert,
Roth, Creaser, & Howard, 1976; Sharf, Primavera, & Diener, 2010). In a meta-analytic
review of 11 studies that included 1,301 clients (mean n per study = 118), Sharf et al. (2010)
found a moderately strong relationship between the working alliance and premature
termination (d = .55). Notably, this effect size is greater than that found for SES and
ethnicity (d = .37 and d = .23, respectively) by Wierzbicki and Pekarik (1993). In particular,
problems with client-therapist agreement on therapeutic tasks have been found to be
associated with ending treatment early (Hawley & Weisz, 2003; Tracey, 1986; Tryon &
Winograd, 2011), however, Sharf et al. did not test this hypothesis in their meta-analysis.
Interestingly, Sharf et al. found that education moderated the relationship between working
alliance and dropout. Studies with larger proportions of clients who completed high school or
more education resulted in reduced correlations between alliance and dropout. Given fairly
consistent findings that clients with less education are more likely to drop out of
psychotherapy, Sharf et al. speculated that individuals with more education are more likely to
complete treatment in the first place, rendering the association between alliance and dropout
less robust. Alternatively, perhaps highly educated clients are more similar to their highly
educated therapists, facilitating convergent expectations regarding treatment (Garfield, 1986;
Wierzbicki & Pekarik, 1993).
Other researchers have found that the working alliance mediates the relationship
between pretreatment expectancies and outcome. In the Treatment of Depression
Collaborative Research Program dataset, although client expectancies for outcome predicted
actual improvement (e.g., Sotsky et al., 1991), the positive correlation between clients’
pretreatment outcome expectancies and clinical improvement was mediated by the client’s
contribution to working alliance quality (Meyer et al., 2002). Consistent with Meyer et al.’s
(2002) findings, Joyce, Ogrodniczuk, Piper, and McCallum (2003) found that the working
alliance (rated by both client and therapist) mediated the effect of client pretreatment
outcome expectations on client improvement in short-term individual therapy for various
conditions.
Individual researchers have found mixed results in terms of whether client-rated
(Fitzpatrick, Iwakabe, & Stalikas, 2005; Tryon & Kane, 1990) or therapist-rated alliance
(Tryon & Kane, 1993) predicted session impact, outcome, and unilateral termination.
However, Sharf et al., in their meta-analysis, found no significant differences between client-
rated, therapist-rated, and observer-rated alliance in the prediction of dropout. Tryon,
Blackwell, and Hammel (2007), conducted a meta-analytic investigation examining the
convergence of client and therapist ratings of working alliance (n = 53 studies). Although
client ratings were consistently higher than therapist ratings (d = .63), client-therapist ratings
tended to be moderately positively correlated (r = .36), regardless of client disturbance,
therapist experience, therapy length, alliance measure, or type of treatment. This moderate
correlation tends to be stable over time. Fitzpatrick, Iwakabe, and Stalikas (2005), in a study
of convergence of client-therapist views of the working alliance over the course of a mean
number of 14 sessions (n dyads = 48), found that perspective convergence did not increase as
therapy progressed. Moreover, convergences in perspective did not influence clients’
evaluations of the positive impact of sessions. To date, however, no research has examined
how client-therapist convergence in ratings of the working alliance may differ when
termination is unilaterally versus mutually determined. Study 2 was designed to address this
question by comparing client-therapist ratings of the working alliance between two groups
were a) both client and therapist agreed that termination was the client’s unilateral decision,
versus b) both the client and therapist agreed that termination was mutually determined. I
expected that both client and therapist alliance ratings would be both higher and more
congruent in the mutual versus unilateral group.
Barriers to Treatment Participation
Kazdin and colleagues have focused on the importance of therapy-specific barriers in
the search for causes of unilateral termination (Kazdin, Holland, Crowley, & Breton, 1997;
Kazdin & Wassell, 1998). In Kazdin’s barriers to treatment model, barriers include the extent
of: a) practical obstacles to participation in treatment (e.g., transportation difficulties,
scheduling conflicts), b) perceptions of treatment as demanding, costly, too long, or difficult,
c) perceptions of treatment as irrelevant to the problems experienced by the client, and d) a
poor therapeutic relationship with the therapist. Kazdin et al. (1997) studied treatment
barriers in the context of family treatment for youth with conduct problems (n = 260
children). Barriers to treatment added to the prediction of unilateral termination beyond the
contribution of client characteristics (income, ethnicity, level of education), and that both
therapist and parent perspectives contributed uniquely to predict dropping out of treatment.
The shared variance between parent-rated and therapist-rated barriers was about 15%. In
study 2, I examined whether these barriers to treatment found to be significant contributors to
dropout in child and family services could also serve as useful ways to distinguish adult
clients who unilaterally terminated from those who mutually decided with their therapists to
end treatment. Client-therapist ratings of the barriers to treatment participation were
examined between two groups in which a) both client and therapist agreed that termination
was the client’s unilateral decision, or b) both the client and therapist agreed that termination
was mutually determined. I expected that both client and therapist ratings of barriers would
be both lower and more congruent in the mutual versus unilateral group.
Concordance between Client and Therapist Perspectives on Termination
Clients and therapists tend to have divergent perspectives about several aspects of
therapy. For example, clients generally anticipate that they will require fewer sessions to
address their problems than do their therapists (Garfield, 1994; Swift & Callahan, 2008), and
therapists tend to overestimate treatment length and underestimate the number of clients who
will terminate unilaterally (Lowry & Ross, 1997; Mueller & Pekarik, 2000; Pekarik, 1992;
Pekarik & Finney-Owen, 1987; Pulford, Adams, & Sheridan, 2008). Some perspective
divergences are more potentially problematic than others. For example, research on the
working alliance shows that clients reliably rate the alliance as higher than do their
therapists, but that this does not impact treatment outcome (Fitzpatrick et al., 2005).
However, as discussed, divergent expectations for the content and process of treatment can
lead to an increased risk of unilateral termination (Corning, Malofeeva, & Bucchianeri, 2007;
Gunzburger et al., 1993; Horenstein & Houston, 1976).
In line with this, it is important to consider both client and therapist views in order to
understand reasons for termination. Researchers have shown that client and therapist
perspectives on reasons for termination tend to diverge (e.g., Gager, 2004; Hunsley et al.,
1999; Pekarik & Finney-Owen, 1987; Todd et al., 2003). There are only three studies that
have examined the views of therapists with respect to clients’ reasons for termination
(Hunsley et al., 1999; Perkarik & Finney-Owen, 1987; Todd et al., 2003). These studies have
compared client and therapist reasons for termination and have found that therapists and
clients tend to agree about reasons related to improvement in therapy and circumstantial
barriers, however, clients’ negative perceptions of therapy often go unnoticed by therapists,
or are attributed to low client motivation or to clients’ lack of time.
Pekarik and Finney-Owen (1987) surveyed 173 therapists from community mental
health clinics regarding the primary reasons why clients left therapy unilaterally. They asked
therapists, in general, to list top reasons why clients leave, and compared these with reasons
given by a sample of clients (n = 46) from one community mental health clinic (Pekarik,
1983b). Clients were contacted by researchers 3 months after unilateral termination and
directly asked their reasons for termination. They found that therapists and clients tended to
agree about positive reasons for termination (problem solved or improved was endorsed by
39% of clients and by 31% of therapists) and obstacles to treatment (environmental
constraints was endorsed by 35% of clients and by 37% of therapists). However, when the
focus was on termination due to failed therapy, there was very little agreement between
clients and therapists (resistance was endorsed by no clients and by 22% of therapists; dislike
of therapy/therapist was endorsed by 26% of clients and by 11% of therapists). Because both
sets of researchers asked about reasons for client decisions, in general, memory and heuristic
biases (Garb & Boyle, 2004) might have affected their abilities to accurately report on
reasons for termination. Given evidence that therapists spend most of their time with longer
term, mutually terminating clients, their perceptions of the proportion of unilaterally
terminating clients may be inaccurate (Vessey et al., 1994).
In order to garner therapist perspectives on specific clients, Hunsley et al. (1999)
compared training clinic therapists’ reasons for client termination written in their final
reports with reasons reported directly from interviews with former clients (n = 87). They also
found that therapists and clients made different attributions about failed therapy. Their results
suggest that therapists were not aware of, or did not report, clients’ dissatisfaction with
therapy as the primary reason for termination; no client was described by a therapist as
terminating because of dissatisfaction with therapy. However, 10 clients reported that the
fact that therapy made things worse for them was very important in their decision to end
therapy. Almost half (n = 4) of these clients were described by therapists as terminating
because they no longer had the time or interest to continue therapy. Thirteen clients reported
that the feeling that therapy was going nowhere was very important in their decision to end
treatment. For these clients, one-third (n=4) were described by therapists as ending therapy
because they had achieved many or all of their goals, and another third (n = 4) were
described as terminating because they no longer had the time or interest in continuing
therapy. In sum, therapists were not accurate at detecting treatment failure, and the reasons
for the failure, from the client’s perspective. Hunsley et al. also found that therapists did not
always recognize client perceptions of improvement. Among the 32 clients who were
identified by therapists as leaving because they achieved their goals, 75% of the clients
reported this reason as important to their decision to leave. On the other hand, of the 33
additional clients who reported ending therapy because of achieving their goals, only 16
(48%) were identified by therapists as having achieved their goals.
Also examining therapist perspectives on specific clients, Todd et al. (2003) found
similar lack of concordance using a qualitative coding methodology to examine training
clinic therapists’ reasons for client termination provided on routine clinic forms with reasons
reported on similar forms given to clients at termination. Their results suggest only moderate
overall agreement between therapist and client reasons (Cohen’s " = .43). More specifically,
clients and therapists showed good agreement on client environmental and therapist
environmental reasons, fair agreement on improvement reasons, and poor agreement on
client negative and other reasons. Therapists were significantly more likely than clients to
endorse improvement as a reason for termination, and clients were more likely to endorse
client environmental and other reasons.
Both Hunsley et al. (1999) and Todd et al. (2003) used a file-review methodology
whereby either final reports or standard clinic forms were reviewed to obtain therapist
reasons for termination. It is possible that graduate student therapists’ reports may reflect
efforts to please their supervisors, or other constraints on report writing and record keeping,
rather than actual therapist perceptions. Study 2 of the proposed dissertation was designed to
fill this gap by examining within-dyad client-therapist perspectives, with information
collected prospectively by an impartial researcher, and garnering parallel data from clients
and therapists at the same point in time. Furthermore, Study 2 was designed to examine
perspective divergence in the context of unilateral versus mutual termination from therapy. I
predicted that, in dyads where termination was mutual, compared with dyads where
termination was a unilateral decision on the client’s part: 1) both clients and therapists would
rate having accomplished therapy goals as more important to the termination decision, and
circumstantial and therapy-specific reasons as less important to the termination decision. I
also predicted that client and therapist perspectives on the client’s reasons for termination
would be more congruent in the mutual versus unilateral group. In other words, I expected
that therapists would be more aware of their clients’ reasons in the mutual versus unilateral
group.
Beyond simply elucidating perspective divergences between client and therapists
reasons for termination, it is important to understand the factors that contribute to perspective
divergence. Therapists may underestimate clients’ positive therapy gains due to differences
in expectations and because clients may not communicate positive changes, and therapists
may be unable to fully appreciate negative reactions in treatment because clients may hide
these feelings (e.g., Hill, Thompson, Cogar, & Denman, 1993; Hannan et al., 2005; Regan &
Hill, 1992). For example, Regan and Hill (1992) asked 24 clients at a training clinic to write
down thoughts and feelings they had during a therapy session that they did not share with
therapists. They also asked therapists to write down thoughts and feelings they thought
clients had but did not share. Most things clients left unsaid were negative, and therapists
were able to match only 17% of the total number of things clients left unsaid during sessions.
Further research suggests that experienced therapists may not be more adept at perceiving
client negative reactions than are trainees (Hill, Thompson, Cogar, & Denman, 1993).
Whether due to attributional biases (Malle, 2006; Campbell & Sedikides, 1999;
Kendall et al., 1992; Murdock, Edwards, & Murdock, 2010) or other phenomena, existing
research indicates that even experienced therapists may fail to fully recognize their roles in
unilateral termination and less than ideal treatment outcome for some clients. Kendall et al.
(1992) asked 315 experienced therapists about specific clients who had failed to benefit from
therapy. Therapists, across theoretical orientations, rated their clients’ inability to benefit
from and lack of motivation for treatment as the most important reasons for lack of progress,
although rating themselves as the least likely cause of their clients’ lack of progress.
Theoretical orientation influenced therapist perspectives: although ranking their clients’
inability to benefit from therapy as the most important cause of negative outcomes,
cognitive-behavioural therapists attributed significantly less responsibility to the client
compared to attributions made by psychodynamic, humanistic, and eclectic therapists.
Murdock et al. (2010) presented two vignettes to 243 psychologists describing client
unilateral termination that varied only in whether the client was referred to as “your client”
or “the client”. Psychologists rated the causes of the unilateral termination on a continuous
scale; Psychologists showed a self-serving bias, showing a tendency to blame the therapist
when the vignette was “the client” and showing a tendency to blame the client in the “your
client” condition. These researchers also found that, although both men and women showed a
self-serving bias, the size of the bias was larger for men, and for psychodynamic therapists
compared with cognitive-behavioural and existential/interpersonal therapists. Cognitive-
behavioural therapists did not make different attributions for termination in cases where
clients were their own versus others’. It may be that cognitive-behavioural therapists’
training emphasizing environmental influences on behaviour partially mitigates natural
tendencies toward the fundamental attribution error. In addition to examining therapists’
perspectives of client reasons for termination early versus later in therapy, Study 3 was
designed to shed light on how theoretical orientation may influence therapists’ perspectives
on client reasons for termination. Based on this research, Study 3 was designed to test the
hypothesis that psychologists reporting dominant CBT versus other orientations ascribed less
importance to termination reasons that attributed fault to the client.
Reasons for Early versus Later Unilateral Termination
Clients end psychotherapy at various stages during its process (Armbruster & Kazdin,
1994; Barrett et al., 2008). Roughly 50% of individuals scheduling an initial outpatient
mental health appointment actually attend (Sparks, Daniels, & Johnson, 2003; Weirzbicki &
Pekarik, 1993). Of those completing the intake, between 35% and 50% do not attend the first
therapy session (Garfield, 1986; Hansen et al., 2002; Phillips, 1985), and roughly 40% attend
fewer than three sessions (Pekarik, 1983a). Clearly, some clients seek services but choose
not to engage in treatment, other clients engage in treatment but then make unilateral
decisions to end it earlier than therapists deem appropriate, and still other clients engage in
treatment and make mutual decisions with therapists to end. Given that most unilateral
terminators end very early in their treatments, it is especially important to examine factors
that contribute to unilateral termination early in treatment.
Two sets of researchers reported reasons for termination collected exclusively from
clients who terminated very early in treatment. These clients were on a wait-list, attended an
intake, and refused services. Client reasons were heterogeneous: Archer (1984) surveyed 59
clients from a university counselling centre who were on a wait list and refused services.
Clients could indicate multiple reasons: Fifty-one percent felt the intake was enough or that
their problem was resolved, 39% were still interested in services; 19% felt the wait list was
too long, 12% had sought services elsewhere, and 10% were disappointed with their intake
session. Christensen, Birk, and Sedlacek (1975) surveyed 20 wait-list clients from a
university counselling centre who missed their first appointment after an intake session.
Sixty percent reported that their presenting problem was unchanged; 50% sought services
elsewhere; 20% reported that their problem had resolved. These studies suggest that
individuals who drop out before attending any therapy, or terminate after attending one or
two sessions, are a heterogeneous group and further investigation is required to determine the
reasons why some people choose not to follow through with services (Manthei, 1996). It is
clear, however, that many clients who terminate before engaging in therapy do not do so
because their problems have resolved.
Researchers who have examined models of engagement in therapy have been
unsuccessful in their attempts to uncover reliable associations between client characteristics
and engagement in therapy. For example, Rumstein-McKean (2005), in a sample of 155
clients at a university training clinic, examined whether engagement in therapy (defined in
multiple ways as attendance at the third session, client satisfaction, and ratings of the
working alliance) could be predicted by demographic (age, gender, referral source, time on
the waiting list, and psychological distress) and motivational aspects (stage of change, type
of motivation). These factors were not predictive of engagement in therapy. Only time on the
waiting list was a significant (inverse) predictor of attendance of at least three sessions.
Although Rumstein-McKean (2005) did not find support for the above factors in
therapy engagement, there is evidence to suggest that other factors are particularly relevant
to clients’ decisions to terminate their treatments early on. In the following sections, I present
studies examining time on the waiting list, first impressions of clinic facilities and therapists,
satisfaction with the intake session, and circumstantial barriers.
Wait list time. Longer wait times have been repeatedly associated with early
unilateral termination (Barrett, Chua, & Thompson, 2007; Chua & Barrett, 2007; Festinger,
Lamb, Marlowe, & Kirby, 2002; Manthei, 1996; Rumstein-McKean, 2005; Saporito, Barrett,
McCarthy, Iacovello, & Barber, 2003; Stasiewicz & Stalker, 1999). Rumstein-McKean
(2005) found that time on the waiting list strongly predicted whether a client would attend
therapy until at least the third session. The longer a client was on the waiting list, the less
likely the client was to attend at least three sessions of therapy. Even once the intake is
completed, there is some evidence that any uncertainty around the beginning of treatment
contributes to dropout. Rodolfa, Rapaport, and Lee (1983) examined 334 post-intake
returners (93%) and 25 (7%) post-intake unilateral terminators at a university counselling
centre; number of days between intake and counsellor assignment was significantly longer
for non-returners than for returners.
Clinic facilities. Some initial research has shown that factors such as clinic
accessibility and office environment can be salient considerations to early termination.
Barrett et al. (2008) pointed out that many clients complain that the building is uninviting,
waiting rooms are congested and uncomfortable, all clients wait in a single room, and
therapy rooms are small and poorly ventilated. Furthermore, subtle effects of social and
cultural biases of agency personnel have been argued to reduce engagement (Lo & Fung,
2003). However, very little research has examined whether these factors serve to influence
non-return. Chua and Barrett (2007) retrospectively reviewed 127 client records at an urban
community mental health centre. After refurbishing the waiting area and therapy rooms, the
clinic experienced a significant 10% (81 to 91%) increase in attendance at the first treatment
session post-intake. Clients reported significantly greater comfort and satisfaction in the new
facilities as well. Unfortunately, evidence-based guidelines for optimal design of healthcare
environments are lacking (Dijkstra, Pieterse, & Pruyn, 2006).
First impressions of therapists/intake session. Client perceptions of therapist
expertise, attractiveness, and trustworthiness have repeatedly been associated with dropout.
Alcázar Olán, Deffenbacher, Hernández Guzmán, Sharma, and de la Chaussée Acuña
(2010), in a retrospective study, compared 141 post-intake returners to 32 non-returners
(participants were psychology students, and no information was provided about therapists)
and found that clients were less likely to return when they reported feeling badly at the end
of the intake interview. McNeill, May, and Lee (1987) retrospectively studied 56 unilateral
terminators versus 148 mutual terminators at a university counselling centre. They found that
early terminators perceived counsellors as significantly less expert and less attractive than
did mutual terminators. Hynan (1990) mailed out questionnaires to 31 early (fewer than 5
sessions) and later (more than 5 sessions) terminators from a university clinic. Early
terminators retrospectively rated their therapists as less respectful, less warm, and less
competent than did later terminators. All of these studies were retrospective in nature, which
means that they may be affected by biased client perceptions.

When assessed prospectively, several types of therapist characteristics have been
shown to predict unilateral termination. The results in this literature are, however, mixed.
Some studies showed that perceptions of therapists were salient to client dropout (Beckham,
1992; Kokotovic & Tracey, 1987; Mohl et al., 1991), and other did not (Gunzburger et al.,
1985; Grimes & Murdock, 1987). Unfortunately, there is no consistency across studies in
measures, methodology, or definition of premature termination, and all studies are plagued
by relatively small sample sizes. Beckham (1992), in a study of 31 dropouts vs. 24 mutually
terminating clients seen in an outpatient training clinic, found that dropouts rated their
therapists more negatively (i.e., less warm, empathic, and genuine) than did mutual
terminators following the intake session. Kokotovic and Tracey (1987) prospectively
examined return after intake at a university counselling centre in 30 dropouts versus 104
continuers at a university counselling centre and found no differences in perceptions of
counselor attractiveness. However, dropouts rated their therapists as significantly less
trustworthy and expert than did continuers. Dropouts were also significantly less satisfied
with their intake session than were continuers. Mohl et al. (1991) studied 48 continuers vs.
32 early dropouts from a university counselling centre where intakes were conducted with
screening psychiatrists. Clients who chose to continue liked the screening psychiatrist more,
felt that they had gained more understanding, felt they were treated with greater respect,
were more satisfied with the intake, perceived the screening psychiatrist as more active and
rated psychotherapy as significantly more potent than did early dropouts. Grimes and
Murdock (1987) examined 51 clients at a counselling centre. Expertness, attractiveness, and
trustworthiness, rated after the first session, were significantly predictive of outcome at the
fourth session. However, these factors were not predictive of premature termination.
Gunzburger et al. (1985), in a prospective study of 30 therapy completers versus 15

unilateral terminators, found no association between client perceptions of therapist empathy,
warmth, or genuineness and termination status.
Circumstantial barriers. Circumstantial barriers, as previously discussed, are
relevant throughout the therapy process. However, barriers can be a particularly salient
impediment to getting therapy off the ground. Hynan (1990) found that early terminators
retrospectively reported that they left therapy because of situational constraints and
discomfort with services significantly more frequently than did late terminators. Manthei
(1996) retrospectively interviewed 33 no-show and 13 post-intake terminators from a
community clinic. No-show clients cited reasons such as excessive cost (27%), being
waitlisted (36%), and seeking help elsewhere (15%). Clients who attended only one session
provided two main reasons: excessive cost (47%), and seeking help elsewhere (38%). Taken
together, comments from both groups indicated that many clients had practical, rather than
negative, reasons for early termination.
In summary, client reasons for termination may systematically vary at different points
in the therapy process, and our understanding of early termination is likely to be obscured if
researchers examine unilateral terminators as a homogeneous group (Barrett et al., 2008;
Kokotovic & Tracey, 1987). There is a need for studies examining termination reasons given
by clients who unilaterally terminate early in treatment versus at later stages of
psychotherapy. Furthermore, no research has examined therapists’ perspectives of early
versus later client unilateral termination. As discussed, therapists may provide different
perspectives that are important to consider in our understanding of unilateral termination.
Study 3 of this dissertation was designed to examine psychologists’ perspectives of reasons
for termination for clients who unilaterally terminated before the third session, after the third
session, and mutually with the psychologist in order to determine reasons that may be unique
to ending therapy at these distinct points. The third session was chosen as a cut-off because
of its identification as an important milestone in the psychotherapy literature (e.g., Salta &
Buck, 1989), during which the quality of the working alliance is established (Eaton, Abeles,
& Gutfreund, 1988). Furthermore, follow-up studies have shown that clients who terminate
services after attending only one or two sessions of therapy tend to improve less or fare
worse than do clients attending three or more sessions (Pekarik, 1983a; 1983b; 1992). I
expected that client reasons potentially more important to early versus later unilateral
termination might include circumstantial barriers, wait list length, and negative first
impressions.
Therapists Use of Engagement Strategies to Foster Mutual Decisions to End Therapy
A small research literature outlines several therapeutic strategies that therapists can use
to increase engagement in psychotherapy and reduce unilateral termination (Ogrodniczuk,
Joyce, & Piper, 2005; Walitzer, Dermen, & Connors, 1999). In the interest of brevity, I will
refer to these henceforth as engagement strategies. Ogrodniczuk et al. (2005) conducted a
review of 39 clinical and empirical articles describing engagement strategies. Of these 39
articles, 15 empirical studies were found in which the researchers explicitly set out to
investigate such interventions. Pretherapy preparation was examined in 12 studies, 7 of
which showed support for the use of these strategies. Additionally, empirical support was
found for the use of patient selection methods (two studies) and case management strategies
(one study). Ogrodniczuk et al.’s review included discussion of pretherapy preparation, client
selection, time-limited treatment contracts, treatment negotiation, case management,
appointment reminders, motivation enhancement, facilitation of therapeutic alliance, and
facilitation of affect expression. Although Ogrodniczuk et al. distinguished between
facilitating a good working alliance and facilitating affect expression (which Ogrodniczuk et
al. defined as providing a safe environment in which clients can explore both negative and
positive feelings), there is no empirical support for this distinction, so they are considered
together in the current review. In my own review of the literature, I found at least
preliminary empirical support for each of the strategies, although not all of the strategies
have been tested in controlled, prospective evaluations (i.e., treatment negotiation). In the
following section, I present these empirical research findings. In addition, I present
information on tracking client progress (also referred to in the literature as systematic client
monitoring, therapist feedback, etc.), given the abundance of research showing its
effectiveness in improving outcome and increasing retention in therapy.
Pretherapy preparation. Pretherapy preparation techniques are the most widely
studied engagement strategy, and include role induction (educating clients about the rationale
for therapy, treatment process, and prognosis), vicarious therapy pretraining (providing
clients with examples of therapy, such as videos), and experiential pretraining (engaging
clients in a simulation of therapy that is typically conducted in a group therapy context).
Walitzer et al. (1999) reviewed empirical studies of pretherapy preparation and found that 11
of 16 studies evidenced reduced rates of attrition (e.g., Kushner & Sher, 1991; Latour &
Cappeliez, 1994; Walitzer et al., 1999). Role induction is the most commonly described
pretherapy preparation technique in the literature, usually occurs within a single 1-hour
session (Ogrodnizuk et al., 2005), and has been shown to improve client attendance.
Pretherapy preparation can also include presentation of a prototypical therapy session via
video or audiotape. For example, Reis and Brown (2006) randomly assigned 125 outpatients
to either 12-minute videotape preparation or a control condition and found that, on a
continuous measure of the therapist’s perspective of client dropout, clients who were
prepared via videotape had significantly lower scores.

Client selection. Client selection (or client-treatment matching) involves ensuring that
clients are appropriately suited to the modality of therapy offered. Two studies have shown
that client characteristics can be measured and predict success in psychodynamic
psychotherapy or cognitive-behavioural therapy (Baumann et al., 2001; Keijsers et al., 1999).
For example, Baumann et al. (2001) found that the Capacity for Dynamic Process Scale
(which assesses nine client qualities that are believed necessary for success in dynamic
psychotherapies) discriminated between clients who unilaterally terminated versus
completed therapy. Keijsers et al. (1999) found scores on the NML2 (Nijmen Motivation List
2) discriminated between clients unilaterally terminating versus completing cognitive-
behaviour therapy (CBT). Ogrodniczuk et al. (2005) suggested that, following an intake
assessment, clients assessed to be at high risk for unilaterally terminating a particular therapy
may be offered a different treatment, or may be offered pretherapy preparation (e.g., social
skills training prior to group therapy) to increase the likelihood of therapy completion. In
sum, despite the high probability that therapists do engage in client selection to some extent,
there is little empirical evidence to guide their selection decisions for the purpose of reducing
unilateral termination.
Time-limited treatment contracts. Treatment contracts in the context of short-term
services have been found to reduce premature termination rates by half (Sledge et al., 1993).
With regard to less severe disorders (e.g., subsyndromal depression and panic disorder),
planned brief treatments can significantly reduce stress and have been shown to be equally as
effective as time-unlimited therapy (Barkham et al., 1999; Newman, Kenardy, Herman, &
Taylor, 1997; Shapiro et al., 2003). For example, when clients expected treatment to last 8
sessions they showed significantly more improvement than clients who expected treatment to
last 16 sessions (Shapiro et al., 2003). Short-term treatment contracts may be less appropriate
in the context of treatment for interpersonal problems, given evidence that interpersonal
changes usually require longer treatment than do symptomatic concerns (Barber, Morse,
Krakauer, Chittamsn, & Crits-Cristoph, 1997; Barkham, Rees, Stiles, Hardy, & Shapiro,
2002).
Treatment negotiation. Establishing an explicit, agreed-upon treatment plan (e.g.,
establishing agreement on goals and tasks of therapy) prior to therapy commencing is often
advanced as a useful strategy for decreasing unilateral termination (Rainer & Campbell,
2001; Reis & Brown, 1999). Reaching consensus regarding the nature of the client’s
problem, and how the problem should be addressed in therapy, are central components of
establishing a viable plan. Although, to date, no study has directly tested the effectiveness of
establishing an explicit treatment plan, a number of retrospective studies have documented
that unilateral termination was more prevalent when client and therapist could not agree on
the nature of the client’s problem. Tryon and Winograd (2002) reviewed literature on goal
consensus and collaboration in psychotherapy and noted that six of nine studies reviewed
found positive associations between client-therapist goal consensus and therapy engagement.
For example, Epperson, Bushway, and Warman (1983) conducted a study of independently-
rated counsellor (n=34) and client (n = 533) agreement at a university counselling centre.
Only 19% of clients whose therapists recognized their specific problem definition
unilaterally terminated after the intake, compared to 55% of clients who unilaterally
terminated when the therapist failed to recognize the problem. Tracy (1977) examined the
effect of two different types of intake interviews on client return for therapy: a) a traditional
interview where therapists did not share problem formulations with clients, and b) a
behavioural analysis interview where therapists shared case conceptualizations and
negotiated mutual treatment goals. Significantly more clients returned for therapy after the
behavioural analysis interview compared with traditional intakes. Tryon (1986) found that
therapists of engaged clients were better at clarifying client concerns than were therapists of
nonengaged clients. Specifically, engaged clients rated their therapists higher on the item
“To what extent did your therapist identify concerns for which you did not initially seek
counselling?” Tryon and Winograd (2011) recently updated their review, meta-analyzing
studies that examined the relation between goal consensus/collaboration and treatment
outcome from 2000 through 2009. Fifteen studies with a total sample size of 1,302 yielded a
goal consensus-psychotherapy outcome effect size of d = .34 (SD = .19), p<.0001.
Facilitation of the early working alliance. As reviewed earlier in this introduction,
research indicates that the quality of the working alliance between client and therapist is
predictive of unilateral termination (Horvath et al., 2011; Johansson & Eklund, 2005; Saatsi,
Hardy, & Cahill, 2007; Saltzman, Luetgert, Roth, Creaser, & Howard, 1976; Sharf,
Primavera, & Diener, 2010; Tryon & Kane, 1990, 1993). It is therefore essential that
therapists work to form a strong alliance with clients in early sessions, particularly the first
three (Rainer & Campbell, 2001).
Motivational enhancement. Once therapy commences, other psychotherapy
preparatory techniques such as motivational interviewing (MI) are relatively brief and easy
to incorporate into existing practice (Arkowitz & Westra, 2009). MI is a method of
questioning clients that aims to reduce ambivalence and increase motivation to change
(Prochaska & DiClemente, 1982; Prochaska, DiClemente, & Norcross, 1992). Rubak,
Sandbaek, Lauritzen, and Christensen (2005) conducted a systematic review and meta-
analysis of 72 randomized controlled trials (RCTs) using motivational interviewing as the
intervention. MI was shown to be significantly more effective than treatment as usual in
three-quarters of the studies, having equal effects on psychological and physiological

problems. When integrated into the initial intake evaluation, it has been found to reduce
dropout rates by 50% (Carroll, Libby, Sheehan, & Hyland, 2001). Carroll et al. examined its
effectiveness in an RCT of MI versus standard evaluation of 60 individuals referred for
substance abuse evaluation. Clients who received MI were significantly more likely to attend
at least one additional treatment session after the intake (59% versus 29%). Joe, Simpson,
Greener, and Rowan-Szal (1999) found that the use of MI increased both engagement in
treatment and outcome in a sample of 396 daily opioid users from three methadone
maintenance treatment sites. Humfress et al. (2002) found that MI increased clients’
motivation for and attitudes toward treatment. Results are not always positive, however, as
other researchers have shown that MI does not influence treatment retention and outcome
(e.g., Baker, Kochan, Dixon, & Heather, 1994; Colby et al., 1998; Feld, Woodside, Kaplan,
Imsted, & Carter, 2001).
Case management. Practical strategies such as case management, which involves
therapists directly intervening in client affairs such as obtaining employment or housing, has
been found to be effective for keeping clients with serious mental illness engaged in
outpatient community treatment (Stein & Santos, 1998). One group of researchers has
examined its effectiveness for preventing premature termination from psychotherapy.
Miranda, Azocar, Organista, Dwyer, and Arean (2003) found the addition of case
management to group CBT for depressed, low SES medical outpatients resulted in a nearly
50% reduction in unilateral termination relative to group CBT alone. Presumably, at least
some involvement with case management may be particularly beneficial early in treatment
given that everyday life events can significantly influence an individual’s motivation and
serve as barriers to treatment (Barrett et al., 2008).

Appointment reminders. The use of appointment reminders is frequently
recommended in the literature, and they are often used by health care professionals, but only
one study has examined the effectiveness of their use in psychotherapy (Turner & Vernon,
1976). Turner and Vernon found, using an ABAB experimental design alternating baseline
and phone message reminder conditions (N = 1,355) that these appointment reminders
significantly increased attendance (32% baseline versus 11% experimental condition; 25%
baseline versus 14% experimental condition) at intake appointments in a community mental
health setting.
Tracking client progress. A number of studies have suggested that providing
therapists with periodic feedback allows them to adjust treatment activities to both keep
clients who are not on track in therapy longer and foster superior outcomes (e.g., Lambert,
Harmon, Slade, Whipple, & Hawkins, 2005; Lambert & Shimokawa, 2011; Whipple,
Lambert, Vermeersch, Smart, Nielsen, & Hawkins, 2003). Lambert and Shimokawa (2011)
summarized meta-analyses of the effects of different client feedback systems, which ranged
from r = .23 (Partners for Change Outcome Management System, k = 3, n = 558) to r = .33
(Clinical Support Tools feedback condition among clients shown to be off-track in therapy, k
= 3, n = 535), noting that the number of clients who deteriorate can be cut in half by use of
client monitoring systems. Most of this research has focused on feedback about client
functioning (e.g., Lambert et al., 2005). The strength of these results are tempered by Knaup,
Koesters, Shoefer, Becker, and Puschner’s (2009) findings. These authors conducted a meta-
analysis of the effects of providing feedback of treatment outcome to specialist mental health
providers (N = 12 studies). These authors found a significant but small (d = .10) positive
short-term effect on mental health outcome, but not on long-term mental health outcomes
measured by follow-up studies of clients (d = -.06).

Therapist Use of Engagement Strategies in Routine Practice: Impact of Theoretical
Orientation
To date, there has been no research examining the extent to which therapists employ
engagement strategies in routine practice. Furthermore, although the effectiveness of these
strategies has been investigated across a range of therapeutic approaches, and all of the
strategies could conceivably be used by therapists of any theoretical orientation, it is also
unclear whether therapeutic orientation serves to guide therapists in their use of these
strategies. Given that cognitive-behavioural therapy, compared with psychodynamic,
interpersonal, and humanistic therapies, is a more structured, time-limited, circumscribed
intervention, CBT therapists may be more inclined to use more engagement strategies (i.e.,
setting a time limit on treatment, making an explicit treatment plan, and using appointment
reminders; Blagys & Hilsenroth, 2002). Traditionally, these other approaches have been
more centrally focused on the role of the therapeutic relationship in the treatment process,
therefore, therapists of other dominant orientations may place considerable emphasis on
building the early working alliance. These speculations remain untested, and study 3 was
designed to examine psychologists’ use of explicit strategies in an effort to engage clients in
therapy and reduce unilateral termination. Study 3 was also designed to examine the
potential influence of theoretical orientation (dominant CBT versus other) on the frequency
of psychologists’ use of engagement strategies.
Summary
Several studies have examined reasons for termination from the client’s perspective
(Bados et al., 2007; Hunsley et al., 1999; Pekarik, 1983, 1992; Renk & Dinger, 2002; Roe et
al., 2006; Todd et al., 2003). However, there is significant variability in reasons for
termination across these relatively small clinic studies. It remains unclear whether variability
in client reasons for termination is due to differences in measurement, sampling strategies, or
unique aspects of the settings in which the clients received services. A population study
examining reasons for termination as garnered by an impartial interviewer, across mental
health settings, is an important contribution to our understanding of client reasons for
termination. The literature also lacks a longitudinal, prospective study examining parallel
client-therapist perspectives of contextual variables in therapy, reasons for termination, and
therapy outcome. This type of study is essential to understand the unique perspectives of
both members of the dyad, and examine perspective divergence in the context of unilateral
and mutual termination decisions. As the majority of the studies in the area have collected
data from trainee therapists, research on experienced therapists’ perspectives of client
reasons for termination remains limited. Furthermore, there is a paucity of research
examining early disengagement from therapy as distinct from attrition occurring later in
treatment (Barrett et al., 2008). Studying and comparing these groups is important to inform
our understanding of issues related to very early termination, particularly given that most
unilateral terminations occur early in treatment. Therapists can use several strategies to
heighten client engagement and increase retention in therapy. However, there is no research
examining whether therapists use these strategies in routine practice. It is necessary to learn
what therapists actually do before initiating efforts to intervene in graduate training and
continuing education.
Overview of Studies and Hypotheses
The present dissertation consists of three separate studies which examine: 1) base
rates of client reasons for psychotherapy termination in Canada, along with their
demographic and clinical correlates, 2) client and therapist perspectives of reasons for
termination, including working alliance and barriers to treatment participation in mutual

versus unilateral terminators, and 3) practicing psychologists’ perspectives of client reasons
for termination at different points in therapy, and their use of engagement strategies to reduce
client-initiated unilateral termination. These studies are drawn from three data sources. I used
data from existing data sets for the first two studies, whereas I collected new data for the
third study: 1) In Study 1, I examined data from the Canadian Community Health Survey,
Cycle 1.2. 2) In Study 2, I examined data collected at the Centre for Psychological Services
at the University of Ottawa from supervised doctoral students in a clinical psychology
program and their clients, 3) In Study 3, I examined data that I collected via a web survey of
Canadian clinical psychologists.
Study 1. Study 1 was designed to examine clients’ self-reported reasons for ending
psychotherapy, across all types of health care providers. An additional goal of the study was
to examine the influence of demographic variables (age, gender, and income), mental
disorder caseness, and type of mental health care provider on odds of indicating each reason
for termination. Based on previous findings in the literature, I hypothesized that low income,
younger age, and meeting caseness criteria for mental disorders (anxiety disorder, mood
disorder, or substance dependence) would decrease the odds of indicating that: a) feeling
better or b) having completed a full course of treatment was the reason for termination. I also
predicted that these variables would increase the odds of selecting other termination reasons
(other than feeling better or completing the recommended treatment). Study 1, which was
published in the Journal of Clinical Psychology, follows this general introduction.
Study 2. Study 2 was designed to examine the congruence in perspectives of client-
therapist dyads regarding important contextual factors in therapy, including clients’ reasons
for termination, working alliance, and barriers to treatment participation. I compared dyad
perspectives between two groups where a) both client and therapist agreed that termination
was a unilateral decision on the client’s part, versus b) both client and therapist agreed that
termination was a mutual decision. I predicted that, in dyads where termination was mutual,
compared with dyads where termination was a unilateral decision on the client’s part: 1) both
clients and therapists would rate having accomplished therapy goals as more important to the
termination decision, and circumstantial and therapy-specific reasons as less important to the
termination decision; 2) both clients and therapists would rate the early working alliance as
stronger, and barriers to treatment participation as fewer and; 3) client-therapist perspectives
would be more congruent regarding reasons for termination, quality of the early working
alliance, and barriers to treatment participation. Study 2 has been published in the journal
Psychotherapy Research.
Study 3. The final dissertation study was designed to examine psychologists’
perspectives of client reasons for termination for three groups of clients: 1) clients who did
not engage in therapy (who unilaterally terminated before the third session), 2) clients who
attended at least three sessions and then unilaterally terminated, and 3) clients who mutually
decided to terminate therapy with the psychologist. When comparing clients who terminated
mutually with the psychologist and clients who terminated unilaterally (both before and after
the third session), I predicted that psychologists would assign higher importance to clients
having achieved their therapy goals, and less importance to all other reasons. I also predicted
that the importance assigned to reasons for early versus later unilateral termination would
differ. For clients who terminated before the third session, versus after the third session,
psychologists would rate circumstantial barriers, a longer wait list time, and client’s initial
negative impressions as significantly more important. I was also interested in how theoretical
orientation served to guide psychologists’ perspectives of reasons for termination. I predicted
that psychologists reporting dominant CBT versus other orientations would ascribe less
importance to reasons that attributed fault to the client (i.e., insufficient motivation; clients
unable to benefit from therapy).
A second study goal was to examine whether psychologists, in routine practice, used
explicit strategies in an effort to engage clients in therapy and reduce unilateral termination.
Several specific hypotheses were formulated: Theoretical orientation would influence the
frequency of psychologists’ use of engagement strategies. Psychologists reporting dominant
CBT versus other orientations would be more likely to use practical strategies such as
appointment reminders, case management, setting a time limit on the number of therapy
sessions, and systematic client monitoring.

Table 1
Studies of Client Reasons for Termination
Study Site/Data Treatment N Client Reasons for Termination (not mutually

collection exclusive)
procedures
Improvement Dissatisfaction Circumstantial
Barriers
Bados et Training CBT 60 unilateral 13.3% 46.7% 40%
al. (2007) clinic/ terminators
therapists
interviewed
clients upon
termination
Hunsley Training Variable 87 44% 34% 8.5%

et al. clinic/file
(1999) review
Hynan University Variable 31 55% 38% 23%

(1990) counselling
centre/mail-
out survey
Pekarik CMHC/phone Variable 46 unilateral 37% 17% 28%

(1983b) and mail-out terminators
survey
Pekarik Public mental Variable 49 unilateral 39% 26% 35%

(1992) health terminators
clinic/mail-out
survey
Renk & Training Variable, 407 23.5% 8.5% 19.9%

Dinger clinic/file largely
(2002) review CBT
Roe et al. Private Long-term 84 45.5% 36.4% 54.6%

(2006) practice/mail- psychodyna
out survey mic therapy
Todd et Training Variable 123 14% 8% 50%

al. (2003) clinic/file
review
Note. CBT = Cognitive-behavioural therapy. CMHC = Community Mental Health Centre.
CHAPTER 2
Reasons for Terminating Psychotherapy: A General Population Study
Westmacott, R., & Hunsley, J. (2010). Reasons for terminating psychotherapy: A general
population study. Journal of Clinical Psychology, 66, 965-977.

Abstract
Clients’ (N=693) reasons for ending psychotherapy and their associations with
demographics, mental disorder caseness, and type of mental health care service provider
were examined. The most frequently reported reason for termination was feeling better,
however, a substantial minority of individuals reported terminating due to treatment
dissatisfaction or wanting to solve problems independently. Lower income was associated
with lower odds of termination due to feeling better and higher odds of termination due to a
perception that therapy was not helping. Meeting criteria for an anxiety disorder, mood
disorder, or for substance dependence decreased the odds of termination due to feeling better.
These findings provide important information on the challenges to the successful completion
of psychotherapy.
Reasons for Terminating Psychotherapy: A General Population Study
For decades, clinicians providing mental health services have been concerned that
many clients end treatment prematurely (e.g., Baekland & Lundwall, 1975; Persons, Burns,
& Perloff, 1988). Meta-analytic evidence, based on the findings of 125 studies, indicates that
nearly 50% of clients terminate psychotherapy before having completed the full course of
recommended services (Wierzbicki & Pekarik, 1993). As a result, this means that a
substantial number of clients discontinue therapy before they are able to fully benefit from
psychotherapeutic services (Hansen, Lambert, & Forman, 2002; Hunt & Andrews, 1992;
Kazdin, Mazurick, & Siegel, 1994; Phillips, 1987).
Despite the longstanding nature of concerns about early termination of therapy, there
is only limited information about why so many clients choose to end their treatments early
(Mash & Hunsley, 1993). Although clinicians have their own perspectives on clients’
reasons, research often finds that there is limited correspondence between clinicians’ views
and the reasons given by clients (e.g., Gager, 2004; Hunsley, Aubry, Vestervelt, & Vito,
1999; Pekarik & Finney-Owen, 1987; Todd, Deane, & Bragdon, 2003). Several clinic-based
studies have investigated the reasons given by clients for terminating psychotherapy (Bados,
Balaguer, & Saldana, 2007; Hunsley et al., 1999; Pekarik, 1983, 1992; Renk & Dinger, 2002;
Roe, Roe, Dekel, Harel, & Fennig, 2006; Todd et al., 2003). One of the most frequently
provided reasons is that clients ended treatment because they were satisfied with the gains
they had made in treatment. Depending on the study, the percentage of clients ending
treatment early because they had achieved their goals ranged from 14% (Todd et al., 2003) to
45.5% (Roe et al., 2006). The frequency with which this reason is given underscores the
importance of not assuming that termination is premature simply because the client ended
services sooner than expected by the therapist (Gager, 2004; Hunsley et al., 1999).
Researchers have also found that many clients decide to end treatment because of
dissatisfaction with the therapy or the therapist. Across studies, the range of clients ending
treatment early for dissatisfaction reasons is from 8% (Todd et al., 2003) to 34% (Hunsley et
al., 1999). Finally, many clients also cite circumstantial barriers as factors in ending
treatment early. Reasons such as difficulties with scheduling, difficulties making child care
arrangements, and financial barriers have been given by 8.5% (Hunsley et al., 1999) to
54.6% (Roe et al., 2006) of clients.
These studies provide invaluable information regarding common reasons given by
clients for ending psychotherapy. Although there are a number of similarities in the reasons
given across these studies, the percentage of clients reporting these reasons varies greatly
from study to study. With so little systematic research in this area, it is impossible to
determine whether this variability is due to differences in measurement, sampling strategies,
or unique aspects of the settings in which the clients received services.
Furthermore, very little is currently known about whether specific reasons for
terminating treatment are associated with client demographic or clinical characteristics. For
example, Roe et al. (2006) found no significant associations between reasons given for
termination and client gender, age, family status, or education. Pekarik (1983) found
evidence of improvement during treatment among clients who cited circumstantial barriers
and those who reported no longer needing services as their reasons for terminating. However,
he also found no improvement occurred during treatment among clients who terminated
because they were dissatisfied with therapy. Thus, although some clinic-based studies have
examined correlates of specific reasons for termination, too few studies have been conducted
to allow any general conclusions to be drawn.

Most of the studies of clients’ reasons for termination used data obtained from client
files or former clients of clinics in which mental health services were routinely provided. In
most instances, these clients had received services from psychology training clinics.
Exceptions to this include Pekarik (1983, 1992), who sampled outpatients of community
mental health centers, and Roe et al. (2006), who sampled patients in psychodynamically
oriented private practice. The limited variability in the types of client samples and clinical
settings that have been examined poses considerable challenges in trying to generalize the
results of the individual studies to typical psychotherapeutic practice. Furthermore, previous
studies have indicated that, compared to other practice settings, the rate of client change in
training clinics is likely to be slower and treatment is likely to be less effective in reducing
symptomatic distress (e.g., Callahan & Hynan, 2005). Therefore, studies of reasons for
termination in training clinics may have limited generalizability.
Data collected in national population surveys can provide a more accurate and
comprehensive picture of why clients end psychotherapy, due to the absence of any demands
on the client to please the therapist, the random sampling of clients of diverse demographic
characteristics, and the inclusion of a diversity of psychotherapy providers and service
locations. Several clinic-based studies found that many clients left treatment without
providing any reasons for terminating (Bados et al., 2007; Renk & Dinger, 2002; Todd et al.,
2003); data from a national survey can also serve to elucidate reasons given by individuals
such as these by obtaining termination information from a random sample of former clients,
not only those willing to share potentially negative information with therapists. Thus
knowledge of these population-based rates of reasons for client termination can contribute to
therapists’ awareness of clients’ reasons for ending therapy.

Data from two large scale epidemiological survey studies indicated that low income,
young age, lack of insurance coverage for mental health treatment, viewing mental health
treatment as ineffective and being embarrassed about seeing a health provider, minority
ethnic status, having severe psychological distress, and having a diagnosed mental disorder
are all associated with premature termination from mental health services (Edlund et al.,
2003; Wang, 2007). However, both Edlund et al. (2003) and Wang (2007) examined
premature termination from all forms of mental health treatments, including
pharmacotherapy and psychotherapy, and from all types of service providers, including
general health care providers, specialist mental health care providers, and providers outside
of any health care system (e.g., members of the clergy). Therefore, the extent to which their
findings are relevant to client reasons for terminating psychotherapy, specifically, is unclear.
The Present Study
The present study used data collected for the population-based Canadian Community
Health Survey, Cycle 1.2 (Mental Health and Well-Being; Statistics Canada, 2003). The first
aim of the study was to examine clients’ self-reported reasons for ending psychotherapy,
across all types of health care providers and regardless of whether the decision to terminate
services was made unilaterally by the client or in consultation with the treating health care
provider. Despite their dual role in providing medication and psychotherapy, we included
general practitioners and psychiatrists in the present study. General practitioners are the most
widely consulted professional for mental health reasons (Robiner, 2006). Furthermore, a
small but significant number of general practitioners concentrate their practice around the
provision of psychotherapeutic services (V. Winterton, personal communication, January 26,
2010). Despite many psychiatrists who favour psychopharmacological approaches to
treatment, the provision of psychotherapy remains a central aspect of psychiatric services.

Attesting to this, the Canadian Psychiatric Association issued a position statement
characterizing the provision of psychotherapy as an integral component of psychiatric care
(Chaimowitz, 2004). American data indicate that close to 30% of visits to a psychiatrist
involve psychotherapy, and that over 10% of psychiatrists provide psychotherapy to all of
their patients (Mojtabai & Olfson, 2008). Therefore, we viewed including these practitioners
as crucial to determining representative reasons for termination.
The second study aim was to examine the influence of demographic variables (age,
gender, income), mental disorder caseness, and type of mental health care provider on odds
of indicating each reason for termination. In accord with previous research, we hypothesized
that low income, younger age, and meeting caseness criteria for mental disorders (anxiety
disorder, mood disorder, or substance dependence) would decrease the odds of selecting
feeling better or having completed a full course of treatment as a reason for termination. We
also hypothesized that these variables would increase the odds of selecting other termination
reasons (other than feeling better or completing the recommended treatment). Although
rather broad in nature, our hypotheses were designed to reflect what is currently known about
the correlates of specific client reasons for termination.
Methods
Participants and Procedure
Data for this study came from the Canadian Community Health Survey 1.2 (CCHS
Mental Health and Well-being; Statistics Canada, 2003). Developed by Statistics Canada, the
CCHS 1.2 was the first national mental health survey conducted in Canada. The total sample
size for the CCHS 1.2 comprised 36, 984 individuals aged 15 years and over living in private
dwellings in the 10 Canadian provinces. The survey sample was limited to individuals living
in the community, and therefore excluded persons living on Indian reserves, residing in
institutions (e.g., long-term care facilities), employed full-time with the Canadian Armed
Forces, or inhabiting remote regions. The CCHS 1.2 sample was randomly selected from an
area probability frame designed for the Canadian Labour Force Survey. A multistage
stratified cluster design was used to select a sample of dwellings in this area frame. The
households in the selected dwellings then formed the sample of households. One person,
aged 15 or older, was randomly selected from the sampled households. In designing the
sampling frame, a decision was made to over-sample respondents 15 to 24 year olds and
those 65 years and older in order to obtain adequate samples for these age groups.
The provincial response rate for the survey ranged from 73.4% to 82.4% (provincial
average = 77%). Data collection began in May 2002 and extended over seven months. The
content of the interviews was described to potential respondents, and verbal informed
consent was obtained before beginning the interviews. More than 85% of all interviews were
conducted face-to-face and used a computer-assisted application, whereas 14% of interviews
nationally were completed by telephone. The average length for all interviews was less than
70 minutes. The description of the aims, development, and methodology of the CCHS 1.2 are
part of the documentation accompanying the publicly available survey data (Statistics
Canada, 2003) and have also been outlined in detail by Gravel and Beland (2005).
The current study uses data from CCHS respondents who reported that they had seen
a general medical practitioner or mental health professional (psychiatrist, psychologist, social
worker, counselor, or psychotherapist) in the past 12 months about self-defined problems
with emotions, mental health, or use of alcohol or drugs. These respondents were asked,
“With any of these professionals, did you ever have a session of psychological counselling or
therapy that lasted 15 minutes or longer?” If respondents indicated yes, we examined their
subsequent responses to determine if they were eligible for inclusion in our study. This
included respondents who indicated that these contacts took place at (a) a hospital as an
overnight patient, (b) a health professional’s office, (c) a psychiatric outpatient clinic, (d)
some other hospital outpatient clinic, (e) a walk-in clinic, (f) an appointment clinic, (g) a
community health centre/Centre Local de Services Communautaires, drug or alcohol
outpatient clinic, (h) work, (i) school, (j) home, (k) or other (specified by the respondent).
Respondents were then asked “Have you stopped talking to this (health professional)
about your problems with your emotions, mental health or use of alcohol or drugs?” If the
answer was yes, data from these respondents were initially included in the present study. In
total, this yielded a sample of 1,080 participants (711 women, 369 men) who (a) received
psychotherapy for self-defined problems with “emotions, mental health or use of alcohol or
drugs” at some time during the 12 months preceding the interview, (b) terminated treatment
at some point prior to the interview, and (c) provided reasons for ending psychotherapy.
Most participants (96.3%) received fewer than 26 sessions of psychotherapy in total. The
proportion of missing data was less than 5% for all variables. Cases with missing data were
removed from logistic regression analyses. Unfortunately, it was not possible for us to
consider the possible role of client ethnicity in the study because data on ethnicity was not
available in the public use dataset from the survey.
Some respondents reported receiving mental health services from multiple health care
providers. Therefore, to ensure that each respondent contributed only one data point to each
analysis, it was necessary to choose among provider types for respondents who terminated
with more than one provider. Given the present study’s focus on psychotherapy, data on
terminations with medical providers (general practitioners and psychiatrists) were eliminated
from consideration when the respondent also terminated with a non-medical provider
(psychologist, social worker, counselor, or psychotherapist). This ensured the maximum use
of data on service terminations with professionals in which the primary services were
psychotherapy or counseling (as opposed to medical professionals, who may provide
counseling/psychotherapy and medication). When a respondent terminated with both a
social worker and psychologist (n=19), or with a psychiatrist and general practitioner (n=41),
the provider data to be included in the analyses were randomly chosen. One hundred and
seven (9.9%) respondents who were between the ages of 15 and 19 were eliminated due to
known differences in the way youth terminate psychotherapy (Kazdin, 1996; Pekarik &
Stephenson, 1988). These left data from 973 respondents (331 men, 642 women) who were
included in descriptive analyses regarding reasons for termination: 275 (28.3%) individuals
who terminated with a social worker, counselor, or psychotherapist, 276 (28.4%) who
terminated with a psychologist, 239 (24.6%) who terminated with a general practitioner, and
183 (18.8%) who terminated with a psychiatrist.
Measures
Reasons for terminating psychotherapy. Respondents who reported terminating
counselling or psychotherapy services were asked “Why did you stop?” Respondents could
report more than one reason from the following response choices: (a) You felt better; (b) You
completed the recommended treatment; (c) You thought it was not helping; (d) You thought
the problem would get better without more professional help; (e) You couldn’t afford to pay;
(f) You were too embarrassed to see the professional; (g) You wanted to solve the problem
without professional help; (h) You had problems with things like transportation, childcare,
or your schedule; (i) The service or program was no longer available; (j) You were not
comfortable with the professional’s approach; and (k) other reason – specify.
Demographic variables. Variables selected to be used in the present study were age,
gender, and household income (low income versus middle/high income). The mean age of
participants fell within the 35 to 39 age bracket. Low income was defined by self-reported
gross income of less than $15,000 if one to two people per household, less than $20,000 if
three or four people, and less than $30,000 if five or more people. Middle or high income
was defined by the reverse (i.e., more than $15,000 if one or two people, etc.). These income
levels are based on Statistics Canada definitions of low income in Canada. One hundred and
eighty seven (19.2%) respondents fell into the low-income bracket, whereas 762 (78.3%) of
participants fell into the middle to high income bracket. Twenty-four respondents did not
provide data on income (2.5%).
Mental disorder diagnoses. Interview questions for mental health disorders covered
in the CCHS 1.2 were based on the World Mental Health-Composite International
Diagnostic Interview (Kessler & Ustun, 2004), a lay-administered instrument based partially
on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
criteria (American Psychiatric Association, 2000). The 12-month prevalence of these
disorders was assessed. For the present study, respondents were classified as either meeting
or not meeting criteria for the occurrence of at least one disorder from each of three classes
of disorders in the past 12 months: mood disorders (major depressive episode, mania),
anxiety disorders (panic disorder, social phobia, agoraphobia), and substance dependence
(alcohol dependence, illicit drug dependence). In terms of likely mental disorder diagnoses,
220 (23.7%) of the sample met criteria for an anxiety disorder, 399 (41.5%) met criteria for a
mood disorder, 111 (11.4%) met criteria for substance dependence, and, overall, 506 (52.0%)
met criteria for either having an anxiety disorder, a mood disorder, or substance dependence.
Results
Reasons for Termination: Self-Reported Reasons for Termination

The first aim of the present study was to present self-reported reasons for ending
psychotherapy. Given that respondents could indicate more than one reason, we first
examined the frequency of selecting one or multiple reasons. Of the total sample of 973, 159
respondents (16.3%) did not select one of the predetermined reasons, but instead only
selected “other reasons”. These respondents were excluded from main analyses due to the
unknown, heterogeneous nature of the “other” category. Of the remaining individuals, the
vast majority (n = 693, 85.1%) indicated only one reason for termination. Eighty-three
respondents chose two reasons and a total of 38 respondents endorsed three or more reasons.
The data from these respondents who indicated more than one reason were not included in
analyses examining variables associated with specific reasons for termination given the
requirement for independence of outcome in the logistic regression analyses used to test our
hypotheses.
As seen in Table 2, the most frequent reason for termination, reported by just over 40
percent of respondents, was that they felt better. The other most common termination
reasons, each reported by just under 15% of respondents, were (a) that the respondent
perceived that psychotherapy was not helping and (b) that the recommended course of
treatment had been completed. Most of the other possible reasons were reported by around
5% of respondents, except for “you were too embarrassed to see the professional,” which
was indicated by less than 1% of respondents and “You had problems with things like
transportation, childcare, or your schedule”, indicated by 2.1% of respondents. Due to their
low prevalence, these two reasons were not examined further.
Insert Table 2 here
Odds of Selecting Reasons for Termination According to Demographic Variables,
Mental Disorder Diagnoses, and Mental Health Care Provider

Logistic regression was used to determine odds ratios for selecting a reason for
termination as a result of the level of each predictor variable. Age, gender, income level, 12-
month anxiety disorder caseness, 12-month mood disorder caseness, 12-month substance
dependence caseness, and provider type (general practitioner, psychologist, psychiatrist, or
social worker category) were entered into direct logistic regression equations to predict the
odds of selecting a particular reason for termination. Separate models were tested for each
reason for termination. Only the most frequently provided reasons for termination (You felt
better, You completed the recommended treatment, and You thought it was not helping) were
examined with logistic analyses as the remaining reasons were endorsed by so few
individuals that they did not meet assumptions for logistic regression analyses.
Binary logistic regression analyses were conducted on 693 respondents (235 men,
458 women): 202 (29.1%) individuals who terminated with a social worker, counselor, or
psychotherapist, 213 (30.7%) who terminated with a psychologist, 150 (21.6%) who
terminated with a general practitioner, and 128 (18.5%) who terminated with a psychiatrist.
One hundred and thirty-five (19.5%) respondents fell into the low-income bracket, whereas
539 (77.8%) of participants fell into the middle to high income bracket. Nineteen
respondents did not provide data on income (2.7%). In terms of likely mental disorder
diagnoses, 149 (21.5%) of the sample met criteria for an anxiety disorder, 270 (39.0%) met
criteria for a mood disorder, 64 (9.2%) met criteria for substance dependence, and, overall,
338 (48.8%) met criteria for either having an anxiety disorder, a mood disorder, or substance
dependence (Table 3).
Insert Table 3 here
Reason for termination: You felt better. The following characteristics were
associated with significantly decreased odds of selecting you felt better as a reason for
termination: having a low income, meeting criteria for 12-month substance dependence, 12-
month anxiety disorder, or 12-month mood disorder, and having terminated with a
psychiatrist. In accordance with our hypotheses, individuals with middle/high income were
about two and a half times more likely to report terminating due to feeling better (p<.001,
OR, 2.54, 95% CI, 1.63-3.93). Furthermore, compared to other former clients, individuals
meeting 12-month criteria for substance dependence were less than half as likely to report
terminating due to feeling better (p<.05, OR, 0.45, 95% CI, 0.24-0.86). Individuals meeting
12-month criteria for selected anxiety disorders (p<.01, OR, 0.56, 95% CI, 0.37-0.86) and
mood disorders (p<.01, OR, 0.63, 95% CI, 0.44-0.89) were less likely than other former
clients to report terminating due to feeling better. Finally, individuals who terminated with a
psychiatrist were less likely to report feeling better (p<.05, OR, 0.57, 95% CI, 0.34-0.94).
Contrary to hypotheses, neither age (OR, 0.99, 95% CI, 0.93-1.06), nor gender (OR, 0.88,
95% CI, 0.61-1.26) influenced the odds of terminating due to feeling better.
Reason for termination: You completed the recommended treatment. Compared
to other former clients, meeting 12-month criteria for substance dependence significantly
increased the odds of selecting you completed the recommended treatment as a reason for
termination: they were more than twice as likely to report completing treatment (p<.05, OR,
2.23, 95% CI, 1.08-4.59). Contrary to hypotheses, age (OR, 1.00, 95% CI, 0.91-1.11), gender
(OR, 0.93, 95% CI, 0.56-1.57), income (OR, 0.62, 95% CI, 0.35-1.08), 12-month mood
disorder (OR, 1.03, 95% CI, 0.61-1.74), 12-month anxiety disorder (OR, 1.10, 95% CI, 0.61-
1.98), or health professional (OR range .75 to 1.29, all ns) did not influence the odds of
terminating due to completing treatment.
Reason for termination: You thought [psychotherapy] was not helping. Having
low income and having terminated with a psychiatrist increased the odds of selecting you
thought [psychotherapy] was not helping as a reason for termination. Individuals with
middle/high income, compared to those with low income, were approximately half as likely
to report this reason (p<.05, OR, 0.52, 95% CI, 0.31-0.89). Individuals who terminated with
a psychiatrist, compared to other psychotherapists, were over twice as likely to report
terminating due to perceiving psychotherapy as unhelpful (OR, 2.79, 95% CI, 1.42-5.50).
Age (OR, 0.99, 95% CI, 0.90-1.09), gender (OR, 0.85, 95% CI, 0.52-1.42), 12-month mood
disorder (OR, 1.51, 95% CI, 0.92-2.50), 12-month anxiety disorder (OR, 1.00, 95% CI, 0.56-
1.78), and 12-month substance dependence (OR, 0.80, 95% CI, 0.34.-1.88), did not influence
the odds of selecting this reason.
Because of their ability to both prescribe psychotropic medication and provide
psychotherapy, we assumed that one explanation for the different pattern of results for
psychiatrists compared to other professionals was that they were more likely to treat clients
with more severe psychopathology. Because research consistently shows that problem
severity is associated with poorer progress in psychotherapy (Castonguay & Beutler, 2006),
this might explain the pattern of results for former clients of psychiatrists. Therefore, in an
effort to better understand why individuals who terminated with psychiatrists had higher
odds of feeling as though psychotherapy was unhelpful and lower odds of ending treatment
due to feeling better, we examined whether individuals who terminated with psychiatrists
(compared to other professionals) were more likely to be diagnosed with mental disorders.
Indeed, a higher percentage of individuals who terminated with psychiatrists (60%) were
diagnosed with any 12-month substance dependence, anxiety, or mood disorder, compared
with individuals who terminated with other health professionals, (48.30%) , #2(1) = 5.52,
p<.05.
Discussion
The main purpose of this study was to examine data on clients’ self-reported reasons
for ending psychotherapy. In our dataset, the broad sampling of clients and the nature of the
psychotherapy services they received enhance the external validity and generalizability of
our results. On the other hand, the data we used provided no information on the specific
nature of the counseling or psychotherapy services. Undoubtedly, factors such as type of
psychotherapeutic treatment and therapist competence influence reasons for termination;
however, information on these important factors was not included in the survey. The method
of measuring reasons for termination is inherently limited; respondents varied in the length
of time passed between psychotherapy termination and the administration of the survey,
during which time recall biases may have affected their responses. As well, individuals do
not necessarily have access to all the reasons for their decisions, and a more complete picture
of termination is possible when therapist and client perspectives are simultaneously
considered (Westmacott, Hunsley, Best, Rumstein-McKean, & Schindler, 2010). Despite
these inherent limitations in retrospective self-report methodology, we believe it is essential
for both researchers and therapists to be aware of clients’ understanding of their reasons for
terminating psychotherapy.
Given differences in health care systems in Canada and other countries, particularly
the United States, where costs of mental health care fall at least partially to the individual,
the prevalence and predictors of reasons for termination in the present study may not be
generalizable to all health care systems. Edlund et al. (2002) compared mental health
treatment dropouts (defined as individuals who did not select symptom improvement as a
reason for termination) in Ontario, Canada, and the United States, and found no difference in
the proportion of dropouts, the cumulative probability of dropping out across sessions, or the
effects of predictors (sociodemographic variables, mental disorder caseness, and patient
attitudes). However, in the American dataset only, a lack of insurance coverage increased the
odds of dropping out by 1.5 (Edlund et al., 2002). Lastly, the infrequency of some of the
reasons for termination affected our plans to examine patterns of association existing in the
data. All of these limitations must be kept in mind when interpreting our results.
At the most general level, our findings indicated that, despite being given the
opportunity to endorse multiple reasons, a large majority (85.1%) of respondents chose to
indicate only one reason for termination. The most frequently reported reason, ending
therapy because of feeling better, was reported by almost half of respondents (43.4%). This
value is consistent with the proportion of respondents leaving psychotherapy for this reason
in studies involving both a private practice setting (45.5%; Roe et al., 2006) and a university
training clinic setting (44%; Hunsley et al., 1999), but is substantially larger than the values
reported in other recent clinic studies (25% in Renk & Dinger, 2002; 23.5% in Todd et al.,
2003). This underscores the importance of using population-based data to provide estimates
that will have the broadest applicability across settings and service providers.
You completed the recommended treatment was reported by far fewer respondents
(13.4%). The relatively low number of respondents reporting having completed treatment
may reflect the limited number of therapeutic services in Canada that have a predetermined
set of sessions (i.e., limits set by third party payers). It was not helping was endorsed by
14.1% of respondents, and the remainder of the termination reasons were each reported by
about 5% of respondents, with two exceptions. The low prevalence of the first exception,
You were too embarrassed to see the professional (0.4%) may be due to the fact that the
experience of embarrassment surrounding psychotherapy may be a more salient issue in
decisions around treatment seeking and initial engagement rather than treatment termination.
In terms of the second exception, You had problems with things like transportation,
childcare, or your schedule (2.1%) was rated much lower than what would be expected
based on evidence from clinic studies: for example, 35% (Pekarik, 1983), 19.9% (Renk &
Dinger, 2002), 54.6% (Roe et al., 2006), and 53% (Todd et al., 2003). The inability to
overcome circumstantial barriers is undoubtedly an important reason that some people end
treatment, however, it may be that individuals are more apt to provide honest reasons for
termination to an anonymous interviewer rather than clinic staff or research staff affiliated
with the clinic where termination occurred. Despite the prevalence of each of these reasons
being low, taken together, results indicated that at least 44.7% of respondents left
psychotherapy due to some barrier to treatment, preference for solving the problem on one’s
own, or dissatisfaction with psychotherapy (i.e., circumstantial barriers, dissatisfaction,
perceived unhelpfulness, wanting to solve problems without professional help).
The present study is the first population-based study to examine the associations
among specific reasons for terminating therapy with demographic variables, mental disorder
diagnoses, and mental health care provider. Based upon what is known about premature
termination in general, we hypothesized that the odds of selecting You felt better or You
completed the recommended treatment would be decreased by low income, younger age, and
meeting 12-month criteria for mental disorders. We hypothesized that the remaining reasons
for termination would be increased by younger age, low income, and meeting 12-month
criteria for mental disorders. Among these reasons for termination, the only one we were
able to examine statistically was It was not helping, as remaining reasons were not endorsed
by a sufficient number of individuals to be included in inferential analyses. Overall, age and
gender were not found to be associated with odds of selecting any reason for termination. In
accord with previous research (Wierzbicki & Pekarik, 1993; Williams, Ketring, & Salts,
2005), the socioeconomic status indicator low income was a meaningful predictor of
untimely termination from psychotherapy. Low income decreased the odds of termination
due to improvement and increased the odds of termination due to perception that therapy was
not helping.
In terms of clinical variables, meeting criteria for an anxiety disorder, a mood
disorder, or substance dependence decreased the odds of termination due to feeling better.
This finding is particularly troubling as individuals with clinical disorders require the most
help from psychotherapy and, based on the survey data, they are less likely than those
without diagnosable conditions to report that they received the help that they needed to make
improvements in their lives. Meeting criteria for 12-month substance dependence doubled
the odds of completing treatment. This could reflect the typical practice of providing
intensive time-limited treatment programs for substance abuse. The lack of association with
other predictor variables may be due to the heterogeneous reasons underlying treatment
having been completed, including the possibilities that treatment completion may be largely
determined by therapists and that the prescribed number of sessions has only a limited
relation to the clinical profile of clients.
In terms of mental health service provider, only termination with a psychiatrist
significantly affected odds of selecting two reasons for termination. Individuals who
terminated with psychiatrists had decreased odds of terminating due to symptom
improvement and increased odds of terminating due to perceiving therapy as unhelpful.
However, in the present study, there was evidence that, compared to other professionals,
psychiatrists treated more individuals with diagnosable conditions and, thus, more severe
psychopathology. This should be considered when interpreting this finding. Aside from the
data from former clients of psychiatrists, there were no differences in reasons for termination
across mental health professionals and general practitioners. Despite what are likely sizeable
differences in training, experience, and therapeutic approach, differences across professions
were not meaningfully related to reasons for termination.
In sum, the present study examined clients’ self-reported reasons for ending
psychotherapy and the associations among specific termination reasons with demographic
variables, mental disorder diagnoses, and mental health care service provider. The most
frequently reported reason for terminating therapy was that the client felt better. This is
clearly good news for clients and psychotherapists, but it must be tempered by the
recognition that less than half of clients reported leaving psychotherapy due to this reason.
Nearly half of respondents reported leaving psychotherapy due to some barrier to or dislike
of treatment, or because of wanting to solve problems in a different manner. In general,
individuals with low income and diagnosable mental disorders had significantly increased
odds of premature termination. Clearly more attention needs to be paid to identifying client
dissatisfaction and failing psychotherapy before clients leave in order to take steps to
enhance the likelihood that treatment ends in a successful manner (cf. Persons & Mikami,
2002).
References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: Author.
Bados, A., Balaguer, G., & Saldana, C. (2007). The efficacy of cognitive-behavioral therapy
and the problem of drop-out. Journal of Clinical Psychology, 63, 585-592.
Baekland, F. & Lundwall, L. (1975). Dropping out of treatment: A critical review.
Psychological Bulletin, 82, 738-783.
Callahan, J.L., Swift, J.K., & Hynan, M.T. (2006). Test of the phase model of psychotherapy
in a training clinic. Psychological Services, 3, 129-136. Cohen, J. (1992). A power
primer. Psychological Bulletin, 112, 155-159.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that
work. New York: Oxford University Press.
Chaimowitz, G. (2004). Psychotherapy in psychiatry. Ottawa, ON: Canadian Psychiatric
Association.
Edlund, M. J., Wang, P. S., Berglund, P. A., Katz, S. J., Lin, E., & Kessler., R. C. (2002).
Dropping out of mental health treatment: Patterns and predictors among
epidemiological survey respondents in the United States and Ontario. American
Journal of Psychiatry, 159, 845-851.
Gager, F. P. (2004). Exploring relationships among termination status, therapy outcome and
client satisfaction. Dissertation Abstracts International: Section B: The Science and
Engineering, 64 (7-B), 3522. (Abstract number 2004-99002-141)
Gravel, R., & Béland, Y. (2005). The Canadian Community Health Survey: Mental Health
and Well-Being. Canadian Journal of Psychiatry, 50, 573-579.

Hansen, N. B., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response
effect and its implications for treatment delivery services. Clinical Psychology: Science
and Practice, 9, 329-343.
Hunsley, J., Aubry, T. D., Vestervelt, C. M., & Vito, D. (1999). Comparing therapist and
client perspectives on reasons for psychotherapy termination. Psychotherapy, 4, 380-
388.
Hunt, C., & Andrews, G. (1992). Drop-out rate as a performance indicator in psychotherapy.
Acta Psychiatrica Scandinavia, 85, 275-278.
Kazdin, A.E., (1996). Dropping out of child psychotherapy: Issues for research and
implications for practice. Clinical Child Psychology and Psychiatry, 1, 133 – 156.
Kazdin, A. E., Mazurik, J. L., & Siegel, T. C. (1994). Treatment outcome among children
with externalizing disorder who terminate prematurely versus those who complete
psychotherapy. Journal of the American Academy of Child and Adolescent Psychiatry,
33, 549-557.
Kendall, P.C., Kipnis, D., & Otto-Salaj, L. (1992). When clients don’t progress: Influences
on and explanations for lack of therapeutic progress. Cognitive Therapy and Research,
16, 269-281.
Kessler, R. C., & Ustun, T. B. (2004). The World Mental Health (WMH) Survey Initiative
Version of the World Health Organization (WHO) Composite International Diagnostic
Interview (CIDI). International Journal of Methods in Psychiatric Research, 13, 93-
121.
Lebow, J. (1982). Consumer satisfaction with mental health treatment. Psycshological
Bulletin, 91, 244-259.

Link, B. G., & Dohrenwend, B. P. (1980). Formulation of hypotheses about the true
relevance of demoralization in the United States. In B.P. Dohrenwend, B.S.
Dohrenwend, M.S. Gould, B. Link, R. Neugebauer, et al. (Eds.), Mental illness in the
United States: Epidemiological estimates (pp. 114-132). New York: Praeger
Publishers.
Mash, E. J., & Hunsley, J. (1993). Assessment considerations in the identification of failing
psychotherapy: Bringing the negatives out of the darkroom. Psychological Assessment,
5, 292-301.
Mojtabai, R., & Olfson, M. (2008). National trends in psychotherapy by office-based
psychiatrists. Archives of General Psychiatry, 65, 962 - 970.
Pekarik, G. (1983). Improvement in clients who have given different reasons for dropping
out of treatment. Journal of Clinical Psychology, 39, 909-913.
Pekarik, G. (1992). Relationship of clients’ reasons for dropping out of treatment to outcome
and satisfaction. Journal of Clinical Psychology, 48, 91-98.
Pekarik, G., & Finney-Owen, K. (1987). Outpatient clinic therapist attitudes and beliefs
relevant to client dropout. Community Mental Health Journal, 23, 120-130.
Pekarik, G., & Stephenson, L.A. (1988). Adult and child client differences in therapy
dropout research. Journal of Clinical Child Psychology, 17, 316-321.
Persons, J., Burns, D. D., & Perloff, J. M. (1988). Predictors of dropout and outcome in
cognitive therapy for depression in a private practice setting. Cognitive Therapy and
Research, 12, 557-575.
Persons, J. B., & Mikami, A.Y. (2002). Strategies for handling treatment failure successfully.
Psychotherapy: Theory, Research, Practice, Training, 39, 139-151.

Phillips, E. L. (1985). Psychotherapy revisited: New frontiers in research and practice.
Hillsdale, NJ: Erlbaum.
Phillips, E. L. (1987). The ubiquitous decay curve: Service decline similarities in
psychotherapy, medicine, and addiction. Professional Psychology, Research, and
Practice, 18, 650-652.
Renk, K., & Dinger, T. M. (2002). Reasons for therapy termination in a university
psychology clinic. Journal of Clinical Psychology, 58, 1173-1181.
Robiner, W.N. (2006). The mental health professions: Workforce supply and demand issues,
and challenges. Clinical Psychology Review, 26, 600-625.
Roe, D. Dekel, R., Harel, G., & Fennig, S. (2006). Clients’ reasons for terminating
psychotherapy: A quantitative and qualitative inquiry. Psychology and Psychotherapy:
Theory, Research, and Practice, 79, 529-538.
Statistics Canada (2003). Canadian community health survey mental health and well-being.
Retrieved from: http://www.statcan.ca/english/freepub/82-617-XIE/index.htm.
Todd, D. M., Deane, F. P., & Bragdon, R. A. (2003). Client and therapist reasons for
termination: A conceptualization and preliminary validation. Journal of Clinical
Psychology, 59, 133-147.
Wang, J. (2007). Mental health treatment dropout and its correlates in a general population
sample. Medical Care, 45, 224-229.
Westmacott, R., Hunsley, J., Best, M., Rumstein-McKean, O., & Schindler, D. (2010). Client
and therapist views of contextual factors related to termination from psychotherapy.
Psychotherapy Research, 20, 423-235.
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout.
Professional Psychology: Research and Practice, 24, 190-195.

Williams, S.L., Ketring, S.A., & Salts, C.J. (2005). Premature termination as a function of
intake data based on ethnicity, gender, socioeconomic status, and income.
Contemporary Family Therapy, 27, 213-231.

Table 2
Endorsement of Reasons for Termination (N = 973)
Reason for termination All providers
n (%)
You felt better 422 (43.4)
You completed the recommended treatment 130 (13.4)
You thought it was not helping 137 (14.1)
You thought the problem would get better w/o more professional help 64 (6.6)
You couldn’t afford to pay 49 (5.0)
You were too embarrassed to see the professional 4 (0.4)
You wanted to solve the problem without professional help 50 (5.1)
You had problems with things like transportation, childcare, or your schedule 20 (2.1)
The service or program was no longer available 41 (4.2)
You were not comfortable with the professional’s approach 70 (7.2)
Other reasons 188 (19.3)

Table 3
Demographics of Participants Included in Inferential Analyses (N = 693).
N = 693
Income
Low 19.5
Middle/High 77.8
Age (years)
20 – 39 53.2
40 – 59 38.9
60 + 7.9
Gender
Female 66.1
Male 33.9
Health Professional
Social worker, counselor, or psychotherapist 29.1

Psychologist 30.7
General Practitioner 21.6
Psychiatrist 18.5
Mental disorder caseness
Anxiety disorder 21.5
Mood disorder 39.0
Substance dependence 9.2
Any disorder 48.8

CHAPTER 3
Psychotherapy:
A Comparison between Unilateral and Mutual Terminators

Abstract
Contextual variables potentially influencing premature termination were examined. Clients
(n=83) and therapists (n=35) provided parallel data on early working alliance, psychotherapy
termination decision (unilateral versus mutual), clients’ reasons for termination, and barriers
to treatment participation. When clients unilaterally ended therapy, therapists were only
partially aware of either the extent of clients’ perceived improvements or their
dissatisfaction. When termination was mutually determined, there were no differences
between client and therapist ratings of termination reasons. Although working alliance and
barriers to treatment participation were rated as lower in the context of unilateral termination
by clients and therapists, all clients rated the early alliance and barriers to treatment more
highly than did therapists. Results have implications for understanding premature
termination, and suggest future research examining the utility of therapist feedback regarding
contextual variables in terms of retaining clients in therapy.

Psychotherapy
Premature termination of treatment has been a perennial problem in psychotherapy. Up
to 50% of clients discontinue psychological services prematurely (Barrett, Chua, Crits-
Cristoph, Gibbons, & Thompson, 2008; Swift, Callahan, & Levine, 2009; Wierzbicki &
Pekarik, 1993), which undermines the potential benefits of treatment and reduces the cost-
effectiveness of these services (Garfield, 1994; Ogrodniczuk, Joyce, & Piper, 2005; Pekarik,
1985a). Compared to clients who complete treatment, those who leave treatment prematurely
tend to be less satisfied with services (Lebow, 1982), are less likely to have improved
(Pekarik, 1986; Prinz & Miller, 1994; Saatsi, Hardy, & Cahill, 2007), and are more likely to
be impaired, and therefore, more in need of services (Kazdin, Mazurick, & Siegel, 1994).
In order to intervene to prevent premature termination, we need to better understand
why clients leave before their treatments are completed. Most research in this area has
examined who leaves, focusing primarily on static client or therapist factors. Although few
replicable results have been found, there is consistent evidence that premature termination is
associated with socioeconomic disadvantage and non-White ethnicity (Wierzbicki &
Pekarik, 1993; Williams, Ketring, & Salts, 2005). Closer examination of findings such as
these raise the possibility that the association with ethnicity can be largely accounted for by
socioeconomic disadvantage (Garfield, 1994) which, in turn, may be at least partially
explained by differences in client expectations for the duration of treatment (Pekarik, 1991;
Pekarik & Stephenson, 1988; Pekarik & Wierzbicki, 1986). Thus, this line of evidence
suggests that there may be considerable value in examining contextual factors potentially
related to premature termination. In the present study, we examine three such factors: the
reasons clients terminate services, early treatment alliance, and possible barriers to clients’
involvement in therapy.
Premature termination has been defined a number of ways, including failing to attend a
scheduled session, failing to complete a prescribed number of sessions, and making a
unilateral decision to end treatment without agreement of the therapist (Wierzbicki &
Pekarik, 1993). Pekarik (1985b) suggested that a unilateral decision on the part of the client
to terminate best captures the construct of premature termination. This approach
differentiates clients who unilaterally terminate from clients who make a mutual decision
with their therapist to end treatment. It also avoids the problem of defining premature
termination as the failure to complete a prescribed number of sessions, as some clients
achieve the necessary gains in functioning prior to the end of a set number of sessions.
Defining premature termination according to the type of decision addresses the problem of
appropriately classifying clients who meet their treatment goals with few therapy sessions as
well as clients who may remain in therapy for a longer period of time, but leave before their
goals have been reached. Since Pekarik’s suggestion, most researchers have used this
operationalization (e.g., Callahan, Aubuchon-Endsley, Borja, & Swift, 2009; Chisolm,
Crowther, & Ben-Porath, 1997; Keijsers, Kampman, & Hoogduin, 2001; Richmond, 1992;
Smith, Subich, & Kalodner, 1995; Tryon & Kane, 1993).
A wealth of evidence indicates that obtaining data from both clients and therapists is
necessary to understand the process of psychotherapy. Some perspective divergence between
clients and therapists is expected, and a growing body of research documents that both
similarities and differences in perspective can provide insight into the nature of client and
therapist experiences in therapy (e.g., Reis & Brown, 1999; Tryon, Blackwell, & Hammel,
2007; Weiss, Rabinowitz, & Spiro, 1996). Accordingly, it is important to consider both
client and therapist views in order to understand clients’ unilateral termination. For example,
clients generally anticipate that they will require fewer sessions to address their problems
than do their therapists (Garfield, 1994; Swift & Callahan, 2008), and therapists tend to
overestimate treatment length and underestimate the number of clients who will terminate
prematurely (Lowry & Ross, 1997; Mueller & Pekarik, 2000; Pekarik, 1992; Pekarik &
Finney-Owen, 1987; Pulford, Adams, & Sheridan, 2008). Research has shown that any major
discrepancy between a client’s expectations and actual treatment content can lead to an
increased risk of premature termination (Horenstein & Houston, 1976). Client-therapist
divergences in estimations of problem severity also decrease the likelihood of mutual
termination decisions (Corning, Malofeeva, & Bucchianeri, 2007). On the flipside, there is
evidence that addressing clients’ role expectations prior to treatment can decrease the rate of
dropout (e.g., Reis & Brown, 2006; Scamardo, Bobele, Biever, 2004; Walitzer, Dermen, &
Conners., 1999; Zwick & Attkisson, 1985). It is thought that this education may decrease
unilateral termination by developing client expectations that are more congruent with what
actually happens in therapy, and more similar to the expectations therapists hold for clients
(Reis & Brown, 2006; Swift & Callahan, 2008).
Reasons for Termination
Studies of client reasons for termination have shed light on why clients leave (e.g.,
Bados, Balaguer, & Saldana, 2007; Hunsley, Aubry, Vestervelt, & Vito, 1999; Pekarik,
1983, 1992; Renk & Dinger, 2002; Roe, Dekel, Harel, & Fennig, 2006; Todd, Deane, &
Bragdon, 2003). Although the proportion of clients reporting a given reason varies greatly
across studies, common reasons reported by clients tend to be that they left because they
were satisfied with progress in treatment, they encountered circumstantial barriers (including
any external obstacles such as difficulties with scheduling, making child care arrangements,
or financial barriers), or that they were dissatisfied with the therapy or the therapist. In line
with our emphasis on the importance of obtaining information from both client and therapist,
research has shown that client and therapist perspectives on reasons for termination tend to
diverge (e.g., Gager, 2004; Hunsley et al., 1999; Pekarik & Finney-Owen, 1987; Todd et al.,
2003). Even when there is some general agreement on the reasons for termination, there are
likely to be important differences in accounting for some termination factors. For example,
Pekarik and Finney-Owen (1987) surveyed therapists and clients from community mental
health clinics in order to compare the ratings of the primary reasons why clients left therapy.
They asked therapists, in general, to list top reasons why clients leave, and compared these
with actual reasons given by a sample of clients. They found that therapists and clients
tended to agree about positive reasons for termination (problem solved or improved was
endorsed by 39% of clients and by 31% of therapists) and obstacles to treatment
(environmental constraints was endorsed by 35% of clients and by 37% of therapists).
However, when the focus was on termination due to failed therapy, there was very little
agreement between clients and therapists (resistance was endorsed by no clients and by 22%
of therapists; dislike of therapy/therapist was endorsed by 26% of clients and by 11% of
therapists). Pulford et al. (2008) recently replicated these results in another adult outpatient
sample.
Hunsley et al. (1999) also found that therapists and clients made different attributions
about failed therapy. These researchers compared training clinic therapists’ reasons for client
termination written in their final reports with reasons reported directly from interviews with
former clients. Their results suggest that therapists were not aware of, or did not report,
clients’ dissatisfaction with therapy as the primary reason for termination; no client was
described by therapists as terminating because of dissatisfaction with therapy. However, 12%
of clients reported that the fact that therapy made things worse for them was very important
in their decision to end therapy. Almost half of these clients were described by therapists as
terminating because they no longer had the time or interest to continue therapy. Fifteen
percent of clients reported that the feeling that therapy was going nowhere was very
important in their decision to end treatment. For these clients, one-third were described by
therapists as ending therapy because they had achieved many or all of their goals, and
another third were described as terminating because they no longer had the time or interest in
continuing therapy. These results indicate that therapists were not accurate at detecting
treatment failure, and the reasons for the failure, from the client’s perspective. With respect
to attributions for treatment success, among the clients who were identified by therapists as
leaving because they achieved their goals, 75% of the clients reported this reason as
important to their decision to leave. On the other hand, of the clients who reported ending
therapy because of achieving their goals, only half were identified by therapists as having
achieved their goals.
Todd et al. (2003) found similar lack of concordance using a qualitative coding
methodology to examine training clinic therapists’ reasons for client termination provided on
routine clinic forms with reasons reported on similar forms given to clients at termination.
Their results suggest only moderate overall agreement between therapist and client reasons
(Cohen’s ! = .43). More specifically, clients and therapists showed good agreement on client
environmental and therapist environmental reasons, fair agreement on improvement reasons,

and poor agreement on client negative and other reasons. Therapists were significantly more
likely than clients to endorse improvement as a reason for termination, and clients were more
likely to endorse client environmental and other reasons.
Both Hunsley et al. (1999) and Todd et al. (2003) used a file-review methodology
whereby either client termination reports or standard clinic forms were reviewed to obtain
therapist reasons for termination. Due to the possibility of the graduate student therapists
trying to please supervisors, as well as other constraints on report writing and record
keeping, actual therapist perceptions regarding reasons for termination might have been
absent from the final report or clinic data. These authors’ results highlight the importance of
examining both client and therapist perspectives on whether termination was unilateral or
mutual. The methodologies used in this research to date have been either file review, general
surveys about reasons for termination given to therapists or clients, or routine administrative
forms used in clinic settings (Hunsley et al., 1999; Pekarik & Finney-Owen, 1987; Renk &
Dinger, 2002; Todd et al., 2003). No study, to our knowledge, has used data from a research
protocol that obtained parallel information from both members of the client-therapist dyad to
examine specific reasons why the client terminated services and how perspective divergences
may be related to unilateral termination.
Therapeutic Alliance
It is well-established that therapeutic alliance, particularly agreement on therapeutic
tasks, is strongly associated with psychotherapy outcome (e.g., Weerasekera, Linder,
Greenberg, & Watson, 2001). In terms of predicting premature termination, although there
have been inconsistencies in the research, working alliance (generally measured after the
third treatment session) has been found to predict premature termination (Saatsi, Hardy, &
Cahill, 2007; Saltzman, Luetgert, Roth, Creaser, & Howard, 1976). In particular, problems
with client-therapist agreement on therapeutic tasks have been found to be associated with
ending treatment early (Tracey, 1986). Meta-analytic research on client and therapist ratings
of working alliance suggest that, although client ratings were higher than therapist ratings (d
= .63), their ratings tend to be moderately positively correlated (r = .36), regardless of client
disturbance, therapist experience, therapy length, alliance measure, or type of treatment
(Tryon et al., 2007). To date, however, no research has examined how client-therapist
congruence in ratings of the working alliance may differ as a function of mutual versus
Barriers to Treatment Participation
Using a barriers to treatment model, Kazdin and colleagues have focused on the
importance of therapy-specific factors in the search for causes of premature termination
(Kazdin, Holland, Crowley, & Breton, 1997; Kazdin & Wassell, 1998). In this model,
barriers include practical obstacles to participation in treatment (e.g., transportation
difficulties, scheduling conflicts), perceptions of treatment as demanding, unhelpful, or
irrelevant to the problems experienced by the client, and a poor therapeutic relationship with
the therapist. Kazdin et al. (1997) found that consideration of these barriers added to the
prediction of premature termination beyond the contribution of client characteristics (income,
ethnicity, level of education), and that these findings were generally consistent across both
parent and therapist perspectives for the reasons that families terminated therapy early. Large
effect sizes were found for the contribution of the perceived relevance of treatment and
stressors, and small and moderate effect sizes were found for the contribution of therapeutic
relationship and treatment demands in discriminating between clients who completed and
those that left treatment prematurely. Interestingly, critical events that had occurred in a
client’s life while they were in treatment (e.g., moving, job loss, illness, change in marital
status) were not found to contribute significantly to premature termination (Kazdin et al.,
1997). Therefore, the present study examined whether these contextual factors found to be
significant contributors to dropout in child and family therapy could also serve as useful
ways to distinguish those adult clients who unilaterally terminated from those who mutually
decided with their therapist to end treatment. We also examined barriers from both client and
therapist perspectives; Kazdin et al. (1997) reported that the shared variance between parent-
rated and therapist-rated barriers was only about 15%.
The Present Study and Hypotheses
In an effort to better understand unilateral termination, the goal of the present study
was to examine the congruence in perspectives of client-therapist dyads regarding important
contextual factors, including clients’ reasons for termination, working alliance, and barriers
to treatment between two groups where a) both client and therapist agreed that termination
was a unilateral decision on the client’s part, or b) both client and therapist agreed that
termination was mutual. Based on previous research, several specific hypotheses were
formulated:
1) We hypothesized that, in dyads where both client and therapist agreed that
termination was a mutual decision, compared with dyads where both client and
therapist agreed that termination was a unilateral decision on the client’s part,
both clients and therapists would rate:

a. having accomplished therapy goals as more important to the termination
decision, and circumstantial and therapy-specific reasons as less important
to the termination decision.
b. the early working alliance as stronger
c. barriers to treatment participation as fewer
2) We hypothesized that, when termination decisions were mutual as opposed to
unilateral, client-therapist perspectives would be more congruent regarding:
a. reasons for termination,
b. quality of the early working alliance, and
c. barriers to treatment participation
Method
Participants
One hundred and fifty-five adult clients seeking individual psychological services from
a university clinical psychology training clinic were initially recruited for a study on the
process of engagement and termination from psychotherapy. The training clinic serves as a
community clinic and operates on the basis of a sliding fee scale. Of these 155 client
participants, 39 completed initial measures for the study while they were waiting for
services, but never attended an initial treatment session, and 9 received services but did not
complete the final set of measures at the end of treatment (either because they could not be
reached by the researchers or were no longer interested in participating). Therefore, data
were available on a total of 107 client participants who received psychotherapy and
completed all study measures. On 12 different demographic measures, there was only one
statistically significant difference between the included 107 participants and the 48
individuals who did not complete final measures. Study participants (107) had a slightly
higher level of education (M = 7.05, SD = 1.68), characterized by some university courses,
than the group who did not complete the study (M = 6.41, SD = 2.09) that was characterized
by college graduation. This finding is consistent with literature suggesting that individuals
with higher education are less likely to drop out of therapy (Garfield, 1994). A comparison of
these two groups on level of psychological distress prior to therapy from both client (SCL-
10) and therapist (GAF) perspectives revealed no significant differences.
Thirty-five therapist participants (28 women, 7 men) provided therapy to between 1
and 11 client participants. Therapists were practicum students and interns in a doctoral
program in clinical psychology and were supervised by registered psychologists.
To determine the type of termination decision, both clients and therapists were asked
whether the decision to terminate therapy was the client’s unilateral decision, or whether the
decision was made with the mutual agreement of the therapist that treatment goals had been
met. Decisions to end therapy based on the failure of the client to attend sessions or to
schedule subsequent appointments were considered to be unilateral decisions, and decisions
to refer the client to other services for any reason (including when practicum students or
interns were ending their training) were considered to be mutual decisions. Thirty-one client-
therapist pairs agreed that termination was a unilateral decision on the client’s part, 52 client-
therapist pairs agreed that termination was a mutual decision made by both client and
therapist together. Twenty-four client-therapist dyads (22.4%) did not agree on the type of
termination decision, thus indicating the importance of collecting data from both
perspectives (12 clients reported unilateral termination whereas their therapists reported
mutual agreement, and 12 clients reported mutual agreement whereas their therapists
reported unilateral termination). Data from these dyads were not used for analyses reported
in this study.
Demographic characteristics of the sample. The mean age of the 83 client
participants (19 males, 64 females) was 31.7 years (SD = 9.9), with a range from 17 to 60. In
general, clients were highly educated (approximately 40% had completed some university or
college education and 46% had attained at least a university undergraduate degree): 28.9%
were students, 37.3% were employed full-time, 20.5% were unemployed, 12.0% were
employed part-time and 1.2% were homemakers. Most participants reported lower to middle
income (based on a median income of $29,000 for persons 15 years of age or older in the
study region; Statistics Canada, 2001a), with 33.8% of clients earning under $10,000, 25.3%
between $10,000 and $20,000, 16.8% between $20,000 and $30,000, 14.4% between
$30,000 and $40,000, and 9.6% over $40,000. Most participants reported their ethnic
background as white (85.5%); other ethnic groups represented in the sample included black
(3.6%), Asian (6%), Aboriginal (1.2%), and other (3.6%). This level of ethnic diversity is
consistent with census data for the study region (Statistics Canada, 2001b). Client
participants reported a range of presenting problems; 36% reported symptoms of anxiety,
31% reported depressive symptomatology, 29% reported relationship problems, 11% had
suffered sexual abuse, and 10% reported anger management problems. Other identified
problems included attention deficit disorder, loneliness, personality disorder, posttraumatic
stress disorder, problems with sexual functioning, and shyness.
The 83 participants were treated by 31 different therapists, who provided therapy to
between 1 and 11 different participants. To determine if there was a problem of dependence
in the data, 56 comparisons of independent sample means were conducted on 8 different

therapist variables comparing 7 groups of therapists who had seen 1,2,3,4,5,7,8, and 11
different clients, respectively. On only one variable were two groups significantly different at
p<.05, suggesting no important differences across study variables in therapists who provided
treatment to different numbers of client participants. Three main therapeutic approaches were
reported being used by therapists: cognitive-behavioral (69.9%), experiential (15.7%), and
interpersonal (14.5%). No statistically significant difference in type of therapeutic approach
used was found between participants who unilaterally and mutually terminated therapy,
"2(2)= 3.25, ns.
Measures
Demographic data. Age, gender, education level, employment status, annual
income, and cultural/ethnic background were requested prior to commencing treatment.
Symptom-Checklist 10 (SCL-10). Derived from the SCL-90 (Derogatis, Lipman, &
Covi, 1973), the SCL-10 (Nguyen, Attkisson, & Stegner, 1983) is a 10-item measure
yielding a single global score reflecting the extent of psychological distress. In the present
study, this scale was used as a general measure of client self-rated symptomatology. Items
were chosen from the three factors from the SCL-90 that were found to be most interpretable
and accounted for a large proportion of the variance in an outpatient population: Depression
(six items; e.g., How much were you distressed by feeling lonely?), somatisation (two items;
e.g., How much were you distressed by feeling weak in a part of your body?), and phobic
anxiety (two items; e.g., How much were you distressed by feeling afraid in open spaces or
on the street?). Items are rated on a 5-point scale of distress (from not at all = 0 to extremely
= 4). Nguyen et al. (1983) and Rosen et al. (2000) found a high level of internal consistency
(Cronbach’s # = .88), indicating that the instrument is an internally consistent measure. In

the current study, the alpha values were .78 at pre-therapy assessment and .85 at post-therapy
assessment. Rosen et al. (2000) found the SCL-10 to show good convergent validity with the
well-developed Symptom Checklist-90 (SCL-90) (r = .92) and discriminant validity with
several other measures of symptom distress that aim to capture more specific aspects of
distress, including the Beck Depression Inventory (BDI) (r = .67), Beck Anxiety Inventory
(BAI) (r = .68), and Mississippi PTSD scale (r = .50). As well, pre-post change scores on the
SCL-10 were examined in relation to those of other measures, and were found to correlate
highly, indicating good sensitivity to change.
Global Assessment of Functioning (GAF) Scale. (American Psychiatric Association,
1994). For the purpose of the present study, the GAF was used as an overall measure of
psychological distress from the therapist’s perspective. The GAF is a rating of overall
psychological functioning on a scale of 1 (the most distressed) to 100 (least distressed)
published in the Diagnostical and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV), designed to be completed by clinicians or researchers. The scale is divided into
10 equal ten-point intervals. For example, a score of 51 to 60 indicates that the client has
moderate symptoms, whereas a score of 61 to 70 indicates that the client has some mild
symptoms. Endicott, Spitzer, Fleiss, and Cohen (1976) reported that five studies revealed
intraclass correlation coefficients ranging from # = .61 to .91. Assessments of validity of the
GAF have indicated moderate to high correlations with other independently rated measures
of overall severity, and sensitivity to treatment change.
Working Alliance Inventory (Short Form). The 12-item Working Alliance
Inventory (WAI-S; Tracey & Kokotovic, 1989) was used to assess working alliance. Based
on the original 36-item scale (Horvath & Greenberg, 1986, 1989), it was developed using the
four highest-loading items from each of three subscales (agreement on tasks, agreement on
goals, and development of a bond), and has equivalent factor structure and internal
consistency (Tracey & Kokotovic, 1989). Busseri and Tyler (2003), in a sample of client-
therapist pairs from 54 university counselling centres, found high correlations between WAI
and WAI-S scores, comparable descriptive statistics, internal consistencies, and subscale
intercorrelations within and across rater perspectives. Predictive validity estimates for WAI
and WAI-S total scales were also very similar, supporting the interchangeability of scores on
the WAI and WAI-S. The measure is designed to be administered in the early stages of
therapy, between the third and fifth sessions. Items are rated on a 7-point scale ranging from
1 (Does not correspond at all) to 7 (Corresponds exactly). Negative items (4 and 10) were
reverse-scored, and all scores were summed to provide a global rating of the working
alliance. Both a client version (WAI-C) and a therapist version (WAI-T) of the short form
WAI were used. In the current study, total scale score reliabilities (Cronbach’s #) were .93
for the client version and .92 for the therapist version.
Barriers to Treatment Participation Scale (BTPS). The BTPS was developed by
Kazdin et al. (1997) for use in the context of the outpatient treatment of children and
families. Written in an interview format, it can be administered in person or by phone, and is
phrased so that both treatment dropouts and treatment completers can answer questions. It
was modified for use in the context of adult treatment by changing 11 out of 44 items, and
eliminating six, therefore leaving a total of 38 items (Best, 2003). In the present study, two
versions of the BTPS were completed; one by the client and the other by the therapist. Items
are rated on a 5-point scale ranging from 1 (never a problem) to 5 (very often a problem) and
cover four general areas: a) stressors and obstacles that compete with treatment, b) treatment
demands and issues, c) perceived relevance of treatment, and, d) relationship with the
therapist. Kazdin et al. (1997) found that principal components analysis revealed a single
global scale factor. Therefore, in the current study, analyses were conducted with the global
score. In the current study, global scale score reliability (Cronbach’s alpha) was .87 for the
client-completed version and .83 for the therapist-completed version. Kazdin et al. (1997)
found that the measure showed convergent validity with other measures of participation in
treatment. Evaluation of the scale revealed either no or low correlation and little shared
variance between perceived barriers and critical events occurring while in therapy, or family,
parent, and child characteristics, thereby demonstrating discriminant validity.
Reasons for termination. Client and therapist perspectives on reasons for
termination were assessed with a measure developed by Hunsley et al. (1999). The 10-item
measure was developed based on possible reasons for termination found in the literature.
Clients and therapists were asked, after the final session, to rate the importance in their
decision to end therapy each of 10 possible reasons for termination. Ratings were made on a
4-point scale (not at all important to very important). The 10 possible reasons for termination
were: a) accomplished what you/he/she wanted to do in therapy, b) could no longer fit time
for therapy into schedule, c) just lost interest in therapy, d) no longer had money or insurance
coverage to pay for therapy, e) felt therapy was going nowhere so ended therapy, f) felt
therapy was making things worse so stopped, g) weren’t confident in therapist’s ability to
help, h) uncomfortable talking about personal matters with therapist, i) therapy didn’t fit with
ideas about what would be helpful, j) decided to go elsewhere for services. The 10 reasons
were examined separately in analyses as the measure was not designed to yield a summary
score.
Procedure
Data collection took place over 35 months. Client participants were assessed at three
different times: 1) following a request for therapy and prior to the intake session
(demographics, client self-rated symptomatology (SCL-10)), 2) after the third therapy
session (working alliance (WAI-S), therapist-rated client functioning (GAF), and 3) at the
end of therapy (to assess retrospectively for contextual factors which may have influenced
the decision to terminate, including reasons for termination and barriers to treatment
participation (BTPS); also assessed post-therapy were client self-rated symptomatology
(SCL-10) and therapist-rated client functioning (GAF). All client data were obtained via
structured telephone interview by a research assistant. Therapist data were obtained by
structured self-report. For Time 3 assessments, clients were contacted for a structured phone
interview within a week of their last therapy session if they completed treatment in a planned
manner. In cases where termination was not planned, clients were contacted within a month
of their last session. The collection of data on therapists’ perspectives at this time point
occurred at the same time as the client data were collected. As indicated previously, the
collection of these data took place in the context of a larger study that examined several other
factors related to psychotherapy engagement and termination. Research ethics board
approval was obtained for all phases of the study, and informed consent was obtained from
all participants following a full presentation of the nature of the study
Results
Preliminary Analyses
Preliminary analyses compared unilateral and mutual terminators on demographic,
psychological functioning, and service variables to (a) ensure that groups were equivalent at
pre-therapy and (b) examine therapy outcome for both groups. Prior to therapy, there were
no significant group differences on client-rated (SCL-10) and therapist-rated (GAF)
psychological distress, gender, ethnic origin, referral source, or duration of presenting
problem. However, unilateral terminators attended significantly fewer sessions; with an
average of 9.7 sessions (SD = 8.1), whereas mutual terminators attended an average of 20.8
sessions (SD = 12.2), t(79.50 ) = -6.25, p<.001.
On the SCL-10, unilateral terminators reported a significant decline in distress over
the course of therapy, with a mean of 17.2 (SD = 6.8) before therapy and 10.3 (SD = 6 9)
post-therapy, t(30) = 5.49, p<.001. Mutual terminators reported a similar pattern, with a
mean of 14.9 at pre-therapy (SD = 7.2) and 6.5 (SD = 5.6) post-therapy, t(52) = 7.72, p<.001.
At post-therapy, mutual terminators were significantly less distressed than unilateral
terminators when symptom distress scores prior to therapy were controlled for, F(1, 80) =
5.46, p<.05. Therapists reported unilateral terminators on the GAF as remaining the same
over the course of treatment (i.e., no significant change), with a mean of 66.6 (SD = 11.0)
prior to therapy and a mean of 66.8 (SD = 10.6) post-therapy, t(30) = -2.3, ns. Therapists
reported mutual terminators’ psychological functioning on the GAF as having significantly
improved over the course of treatment, with a mean of 61.8 (SD = 13.1) pre-therapy and a
mean of 73.5 (SD = 14.2) post-therapy, t(50) = -8.47, p<.001. Post-therapy, mutual
terminators were rated by therapists as having significantly higher functioning than were
unilateral terminators when therapists’ GAF assessments prior to therapy were controlled for,
F(1,79) = 28.60, p<.001.
We examined intercorrelations among variables within each of clients’ and
therapists’ perspectives on the BTPS and WAI-S, and among client and therapist-rated
outcome measures (SCL-10, GAF) and these variables. For both clients and therapists, the
WAI-S and BTPS were moderately negatively correlated (clients r = -.52, p<.001; therapists
r = -.28, p<.05). Both pre- and post-therapy SCL-10 scores were negatively correlated with
client-rated WAI-S (pre; r = -.22, p<.05; post; r = -.30, p<.01), but not with therapist-rated
WAI-S (pre; r = -.14, ns, post; r = -.19, ns). Both pre- and post-therapy SCL-10 scores were
also positively correlated with BTPS from client (pre; r = .31, p<.01; post; r = .32, p<.01) but
not therapist (pre; r = .04, ns; post; r = .01, ns) perspectives. The GAF, pre- and post-therapy,
was positively correlated with both client WAI-S (pre; r = .22, p<.05, post; r = .39, p<.001)
and therapist WAI-S (pre; r = .29, p<.01; post; r = .38, p<.001). Pre-therapy, there was no
association between the GAF and BTPS for clients (r = -.11, ns) or therapists (r = .04 , ns).
Post-therapy, GAF scores were associated with client BTPS (r = -.29, p<.01), but not
therapist BTPS (r = -.12, ns).
Mutual vs. Unilateral Terminators: Reasons for Termination. Hypothesis 1a
We hypothesized that clients’ and therapists’ mean ratings of the importance of
termination reasons would differ between unilateral and mutual termination groups.
Specifically, we expected that both clients and therapists in the mutual group, compared with
the unilateral group, would rate having accomplished therapy goals as more important, and
circumstantial and therapy-specific reasons for termination as less important. A one-way
MANOVA was used to compare means between the two groups (unilateral vs. mutual). The
omnibus test for client-rated reasons was significant, Wilk’s $ = 0.37, F(10, 72) = 12.39,
p<.001, partial %2 = .63. Keeping the familywise alpha at .05, tests of between-subjects
effects indicated that clients who terminated therapy unilaterally assigned less importance
than mutual terminators to Accomplished what you wanted to do in therapy as a reason for
leaving, F(1, 81) = 15.75, p<.001, partial %2 = .16. In contrast, unilateral terminators rated
every other reason [except for Decided to go elsewhere for services, F(1, 81) = 0.49, ns] as
significantly more important than did mutual terminators. These reasons included Could no
longer fit time for therapy into schedule, F(1, 81) = 20.43, p<.001, partial %2 = .20, Just lost
interest in therapy, F(1, 81) = 13.95, p<.001, partial %2 = .15, No longer had money or
insurance coverage to pay for therapy, F(1, 81) = 9.66, p<.003, partial %2 = .11, Felt therapy
was going nowhere so ended therapy, F(1, 81) = 66.17, p<.001, partial %2 = .45, Felt therapy
was making things worse so stopped, F(1, 81) = 20.64, partial p<.001, %2 = .20, Weren’t
confident in therapist’s ability to help, F(1, 81) = 37.68, partial p<.001, %2 = .32,
Uncomfortable talking about personal matters with therapist, F(1, 81) = 25.78, p<.001,
partial %2 = .24, Therapy didn’t fit with ideas about what would be helpful, F(1, 81) = 25.68,
p<.001, partial %2 = .24 (see Table 4).
When comparing therapist ratings across groups, the omnibus test was also
significant, Wilk’s $ = 0.320, F(10, 70) = 14.89, p<.001, partial %2 = .68. Keeping the
familywise alpha at .05, tests of between-subjects effects indicated a pattern of findings
similar to those obtained with the client-ratings. Compared to therapists in the mutual group,
therapists in the unilateral group assigned less importance to Accomplished what you wanted
to do in therapy than the mutual group, F (1, 79) = 36.76, p<.001, partial %2 = .32, and more
importance to all other reasons except Went elsewhere for services, F(1, 79) = .92, ns, No
longer had money or insurance coverage to pay for therapy, F(1, 79) = 5.07, ns, Felt therapy
was making things worse so stopped, F(1, 79) = 6.98, ns, and Therapy didn’t fit with ideas
about what would be helpful, F(1, 79) = 4.02, ns. Reasons rated significantly more important
by therapists of unilateral terminators included: Could no longer fit time for therapy into
schedule, F(1, 79) = 32.25, p<.001, partial %2 = .29, Just lost interest in therapy, F(1, 79) =
37.27, p<.001, partial %2 = .32, partial %2 = .06, Felt therapy was going nowhere so ended
therapy, F(1, 79) = 10.84, p<.001, partial %2 = .12, Weren’t confident in therapist’s ability to
help, F(1, 79) = 15.83, p<.001, partial %2 = .17, and Uncomfortable talking about personal
matters with therapist, F(1, 79) = 13.82, p<.001, partial %2 = .15 (see Table 4).
Congruence between Client and Therapist Views on Reasons for Termination.
Hypothesis 2a
It was expected that client-therapist perspectives regarding termination reasons would
be more similar in dyads that made mutual decisions to terminate therapy, compared with
dyads where both client and therapist agreed that termination was a unilateral decision on the
client’s part. To test this hypothesis, difference scores were calculated by subtracting
therapist ratings from client ratings for each reason for termination separately (see Table 5);
positive values indicate that, on average, the client assigned higher importance to the reason
than did the therapist, and negative values indicate that the therapist assigned higher
importance to the reason than did the client. A series of one-sample t-tests was conducted to
determine whether difference scores were significantly different from zero. In light of the
number of analyses, the alpha level for each comparison was set at .005. Difference scores
that were significantly different from zero are indicated in Table 5.
For mutual terminators, none of the difference scores differed significantly from zero,
indicating that client and therapist ratings of the importance of each reason for termination
were very similar. In client-therapist dyads who agreed that the client made a unilateral
decision to end therapy, clients rated the importance of one termination reason, felt therapy
was going nowhere so ended therapy, t(28) = 3.55, p<.001, d = 0.64, significantly higher
than therapists (Table 5). The magnitude of differences between client and therapist
importance ratings, although in the expected direction, was not large enough to be considered
meaningful for the following reasons: Accomplished what you wanted to do in therapy, t (28)
= 2.51, ns , Felt therapy was making things worse so stopped, t(28) = 2.05, ns, Weren’t
confident in therapist’s ability to help, t(28) = 2.12, ns, and, Therapy didn’t fit with ideas
about what would be helpful, t(28) = 2.16, ns.
To test whether client-therapist perspectives on reasons for termination differed to a
greater extent in the unilateral compared with the mutual termination group, a one-way
MANOVA was conducted to compare the magnitude of difference scores between groups.
The multivariate test of between-subjects effects was significant, Wilk’s $ = 0.58, F(10, 70)
= 5.11, partial %2 = .42, p<.001. Follow-up univariate analyses, keeping the familywise alpha
at .05, indicated that client-therapist difference scores were significantly larger in the
unilateral group for reasons of Felt therapy was going nowhere so ended therapy, F(1, 79) =
22.37, p<.001, partial %2 = .22, Felt therapy was making things worse so stopped, F(1, 79) =
8.14, p<.005,partial %2 = .09, Weren’t confident in therapist’s ability to help, F(1, 79) = 7.93,
p<.005, partial %2 = .09 and Therapy didn’t fit with ideas about what would be helpful, F(1,
79) = 8.44, p<.005, partial %2 = .10. Overall, it appears as though clients who unilaterally
decided to end therapy rated reasons related to the unhelpfulness of therapy as more
important to their termination decisions than did their therapists. It seems as though, even
when therapists recognized that the client made a unilateral decision to leave, therapists may
not have been aware of the full extent of the importance of clients’ negative perceptions of
the therapy experience and of the therapist.

Congruence Between Client and Therapist Views on the Quality of the Working
Alliance. Hypotheses 1b and 2b
Repeated measures analysis of variance with dyad member as the repeated factor was
used to examine hypotheses that: (1b) client-therapist dyads who mutually terminated
therapy would report a stronger working alliance than that reported by the unilateral decision
dyads, and, (2b) clients’ and therapists’ ratings of the working alliance would be more
discrepant when termination was a unilateral decision on the client’s part than when the
decision was mutual. The test of between-subjects effects indicated that client-therapist
dyads in the mutual termination group rated the working alliance slightly but significantly
higher than dyads in the unilateral termination group, F (1, 78) = 5.39, p<.05, %2 = .07. Dyads
in the mutual group reported a mean of 69.71 (SE = 1.30), whereas dyads in the unilateral
group reported a mean of 64.71 (SE = 1.72). The test of within-subjects effects indicated
that, across termination groups, clients rated the working alliance significantly higher than
did therapists, F(1, 78) = 5.08, p<.05, %2 = .06. Clients reported a mean of 68.67 (SE = 1.38),
whereas therapists reported a mean of 65.74 (SE = 1.12). The Dyad member X Termination
status interaction was not significant, indicating that the magnitude of the difference between
client-therapist ratings of the working alliance was similar in unilateral and mutual
terminators, F(1,78) = 3.44, ns.
Congruence Between Client and Therapist Views on Barriers to Treatment
Participation. Hypotheses 1c and 2c
Repeated measures analysis of variance with dyad member as the repeated factor was
used to examine hypotheses that: (1c) client-therapist dyads who mutually terminated
therapy would report fewer barriers to treatment participation than did the unilateral decision
dyads, and, (2c) clients’ and therapists’ ratings of barriers to treatment would be more
discrepant when termination was a unilateral decision on the client’s part than when it was a
mutual decision. The test of between-subjects effects indicated that client-therapist dyads in
the unilateral termination group reported more barriers to treatment than dyads in the mutual
termination group, F(1, 81) = 35.41, p<.001, %2 = .30. Dyads in the unilateral group reported
a mean of 61.50 (SE = 1.56) whereas dyads in the mutual group reported a mean of 49.78
(SE=1.20). The test of within-subjects effects indicated that, across termination groups,
clients reported significantly more barriers to treatment than did their therapists, F(1, 81) =
4.94, p<.05, %2 = .06. Clients reported a mean of 57.48 (SE = 1.30), whereas therapists
reported a mean of 53.80 (SE = 1.27). The Dyad member X Termination status interaction
was not significant, indicating that the magnitude of the difference between client-therapist
ratings of barriers to treatment was similar in unilateral and mutual terminators, F(1,81) =
1.59, ns.
Discussion
In an effort to better understand unilateral termination, the present study examined
the congruence in perspectives of client-therapist dyads regarding important therapeutic
variables, including clients’ reasons for termination, working alliance, and barriers to
treatment between two groups where a) both client and therapist agreed that termination was
a unilateral decision on the client’s part, or b) both client and therapist agreed that
termination was mutual. As hypothesized, results of our study indicated that unilaterally
terminating clients, compared with mutual terminators, rated the importance of having
accomplished their goals in therapy as less important to their decision to end therapy, and
reasons related to circumstantial barriers and dislike of therapist and therapy as more
important to their decision. Therapists reported a similar pattern of results; therapists of
unilateral terminators, compared with therapists of mutual terminators, reported that their
clients’ accomplishing goals in therapy was less important to their decisions, and that reasons
related to circumstantial barriers and dislike of therapist and therapy were more important to
their decisions.
When client-therapist assessments were examined within each dyad, small, but
systematic differences in attributions of clients and their therapists became evident. When
termination decisions were mutual, there was no difference between client and therapist
ratings of the importance of any termination reason. When clients terminated therapy
unilaterally, compared with their therapists, they rated four out of ten reasons for termination
as significantly more important to their decision to leave. They ascribed higher importance to
all of the reasons related to dislike of therapy or therapist: felt therapy was going nowhere so
ended therapy, felt therapy was making things worse, weren’t confident in therapist’s ability
to help, and therapy did not fit with ideas about what would be helpful. Clients and therapists
rated the importance of more benign and circumstantial barriers similarly.
Outcome data collected in the study also reflect a perspective divergence between
clients and therapists in the unilateral, but not the mutual, termination group; unilateral
terminators rated their distress as significantly lower at post-therapy whereas their therapists
indicated no change in functioning. In contrast, clients in the mutual termination group
reported a similar decline in distress from pre-therapy to post-therapy, and their therapists
agreed with them, reporting a significant increase in functioning.
These results build on previous research showing that therapists tend to perceive both
treatment success and failure differently than clients (Hunsley et al., 1999; Pekarik &
Finney-Owen, 1987). Directly comparing client and therapist ratings, results from the present
study indicate that these differences in perception occur exclusively around unilateral
termination. When termination was a unilateral decision on the client’s part, therapists
appeared not to be aware of the extent to which clients’ perceived either success in therapy
(i.e., symptom improvement) or failure. Given the small differences in client and therapist
ratings, therapists were largely aware of clients’ dissatisfaction, but tended to rate the
importance of clients’ dissatisfaction reasons as less important than they actually were. This
could reflect both self-serving biases (whereby therapists are not as likely to rate themselves
too negatively) and differing expectations about what will be accomplished in therapy. It
likely also reflects the limited communication inherent in unilateral decision-making; clients
may be unlikely to share the extent of their negative perceptions of therapy and the therapist.
Results from the present study regarding therapeutic alliance data were in line with
previous research; the early alliance, rated after the third therapy session by both client and
therapist, was related with type of termination decision. As we hypothesized, client-therapist
dyads who made mutual decisions to end therapy reported a stronger working alliance early
in treatment than did client-therapist dyads where the client terminated unilaterally. Contrary
to our expectations that mutually terminating dyads would have more similar perceptions of
the working alliance, regardless of how clients terminated therapy, all clients rated the early
alliance significantly higher than did their therapists. It seems as though the tendency, well-
documented in the literature (e.g., Bachelor & Salame, 2000; Fitzpatrick, Iwakabe, &
Stalikas, 2005; Hersoug, Hoglend, Monsen, & Havik, 2001; Hilsenroth, Peters, & Ackerman,
2004; Tryon et al., 2007), for clients to rate the working alliance as higher than their
therapists holds true in spite of eventual unilateral decisions to leave, and poorer therapeutic
outcome. Fitzpatrick et al. (2005) assessed client-therapist alliance ratings in early, middle,
and late phases of therapy and found that once formed, divergence between client and
therapist remained unchanged, and alliance ratings for both clients and therapists increased
linearly. Although there has been no systematic investigation into why clients rate the
alliance as higher, Tryon et al. (2007) suggested that therapists may rate clients relative to
alliances formed with other clients, while clients may rate therapists in comparison to other
health professionals who may take a less collaborative, more paternalistic role, or to friends
and family members experienced as (naturally) less collaborative.
A similar pattern of results was found for barriers to treatment participation. Both
client and therapist dyads who made mutual decisions to end therapy indicated fewer barriers
to treatment than did clients and therapist dyads where the client made a unilateral decision
to leave. Contrary to hypotheses, there was no difference in client-therapist perspective
congruence between unilateral and mutual decision groups. In general, clients rated barriers
to treatment participation as higher than did therapists. This was the first study, to our
knowledge, that examined Kazdin’s barriers to treatment participation scale in adult clients.
More barriers to treatment reported by clients and therapists of adult clients are associated
with unilateral termination decisions, just as more barriers to treatment reported by parents of
children and adolescents with conduct problems are associated with premature termination in
Kazdin and colleague’s (1997) research on dropping out of child treatment.
Our pattern of results was different than Kazdin et al. (1997) in that clients in our
study reported significantly more barriers than did their therapists, whereas parents of
conduct-disordered children in Kazdin et al.’s study reported significantly fewer barriers than
did their therapists. This may be due to differences in client demographics and presenting
problems, or therapist experience (our study took place in a training clinic). Further research
should be conducted to replicate our results, however, our study indicates that therapists can
expect that as clients experience more barriers, they are more likely to make unilateral
decisions to leave therapy.
As mentioned by Kazdin and Wassell (2000), the timing of assessment of perceived
barriers (and reasons for termination) raises issues, as it was conducted at the end of therapy,
after termination decisions had already been made. Retrospective reporting always runs the
risk of biased recall, however, given the relatively short time frame of treatment, and that the
timing of the post-therapy assessment was within one month after termination, recall bias of
retrospective reporting is less likely. Due to logistical constraints, the time-lag between end
of therapy and completion of the BTPS and the reasons for termination measure was within
one month for unilateral terminators, and within one week for mutual terminators, potentially
adding further measurement biases of an unknown nature. It is possible that treatment
outcome influenced our results: mutually terminating clients were less symptomatic and
higher functioning post-therapy and, therefore, may have reported fewer barriers as a result
of experiencing greater improvement. As Kazdin and Wassell (2000) discussed, assessing
barriers at other therapy points (e.g., early in treatment, or on multiple occasions throughout
treatment) have their own methodological and practical liabilities (e.g., clients not having a
complete idea of barriers early in treatment, confounding number of assessment
administrations with duration in treatment and possibly sensitizing clients to the challenges
of attending psychotherapy). Future research should examine other methods of assessing
barriers to treatment throughout the therapy process.

In conclusion, this was the first study to obtain parallel information from both
members of the client-therapist dyad about specific reasons why the client terminated
services, and to examine how these perspective divergences regarding reasons for
termination, early working alliance, and barriers to treatment participation are related to
unilateral termination. When clients made unilateral decisions to end therapy, therapists were
only partially aware of either the extent of clients’ perceiving success in therapy or with their
dissatisfaction. Although working alliance and barriers to treatment participation were rated
as lower in the context of unilateral termination by both clients and therapists, all clients, in
general, rated the early alliance and barriers to treatment as higher than their therapists.
Future research should examine the utility of providing therapists with feedback regarding
barriers to treatment and other process variables in terms of retaining clients in therapy.
Preliminary research (Manfred-Gilham, Sales, & Koeske, 2002) suggests that therapists use
more engagement strategies (particularly direct discussion of barriers) when they perceive
clients to have more barriers, however, no research has examined how therapists’ use of
these strategies impacts client perception of barriers or influences treatment retention.

References
disorders, 4th Edition. Washington, DC: American Psychiatric Association.
Barrett, M.S., Chua, W.J., Crits-Cristoph, P., Gibbons, M.B., & Thompson, D. (2008). Early
withdrawal from mental health treatment: Implications for psychotherapy practice.
Bachelor, A., & Salame, R. (2000). Participants’ perceptions of dimensions of the
therapeutic alliance over the course of therapy. Journal of Psychotherapy Practice and
Research, 9, 39-53.
Best, M. (2003). Premature termination from adult psychotherapy: Can therapy-specific and
contextual factors help predict who will drop out? (Doctoral dissertation, University of
Ottawa, 2003). Retrieved from ProQuest Digital Dissertations. (AAT NQ89989).
Busseri, M.A., & Tyler, J.D. (2003). Interchangeability of the Working Alliance Inventory
and Working Alliance Inventory, Short Form. Psychological Assessment, 15, 193-197.
Callahan, J.L., Aubuchon-Endsley, N., Borja, S.E., & Swift, J.K. (2009). Pretreatment
expectancies and premature termination in a training clinic environment. Training and
Education in Professional Psychology, 3, 11-119.
Chisolm, S.M., Crowther, J.H., & Ben-Porath, Y.S. (1997). Selected MMPI-2 scales’ ability
to predict premature termination and outcome from psychotherapy. Journal of
Personality Assessment, 69, 127-144.

Corning, A.F., Malofeeva, E.V., & Bucchianeri, M.M., (2007). Predicting termination type
from client-therapist agreement on the severity of the presenting problem.
Derogatis, L.R, Lipman, R.S., & Covi, L. (1973). The SCL-90: An outpatient rating scale –
Preliminary report. Psychopharmacology Bulletin, 9, 13-38.
Endicott, J., Spitzer, R.L., Fleiss, J.L., & Cohen, J. (1976). The Global Assessment Scale: A
procedure for measuring overall severity of psychiatric disturbance. Archives of
General Psychiatry, 33, 766-771.
Fitzpatrick, M.R., Iwakabe, S., & Stalikas, A. (2005). Perspective divergence in the working
alliance. Psychotherapy Research, 15, 69-79.
client satisfaction. Dissertation Abstracts International: Section B: The Sciences and
Garfield, S.L. (1994). Research on client variables in psychotherapy. In S.L. Garfield & A.E.
Bergin (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 190-228).
New York: John Wiley.
Hersoug, A.G., Hoglend, P., Monsen, J.T., & Havik, O.E. (2001). Quality of working
alliance in psychotherapy: Therapist variables and patient/therapist similarity as
predictors. Journal of Psychotherapy Practice and Research, 10, 205-216.
Hilsenroth, M.J., Peters, E.J., & Ackerman, S.J. (2004). The development of therapeutic
alliance during psychological assessment: Patient and therapist perspectives across
treatment. Journal of Personality Assessment, 83, 332-344.

Horenstein, D. & Houston, B.K. (1976). The expectation-reality discrepancy and premature
termination from psychotherapy. Journal of Clinical Psychology, 32, 373-378.
Horvath, A.O., & Greenberg, L.A. (1986). The development of the Working Alliance
Inventory. In L.S. Greenberg and W.M. Pinsof (Eds.), The psychotherapeutic process:
A research handbook (pp. 529-556). New York: Guilford.
Horvath, A.O., & Greenberg, L.S. (1989). Development and validation of the Working
Alliance Inventory. Journal of Counselling Psychology, 36, 223-233.
388.
Kazdin, A.E., Holland, L., Crowley, M., & Breton, S. (1997). Barriers to treatment
participation scale: Evaluation and validation in the context of child outpatient
treatment. Journal of Child Psychology and Psychiatry, 38, 1051-1062.
Kazdin, A.E., Mazurick, J.L., & Siegel, T.C. (1994). Treatment outcome among children
33, 549-557.
Kazdin, A.E., & Wassell, G. (1998). Predictors of barriers to treatment and therapeutic
change in outpatient therapy for antisocial children and their families. Mental Health
Services Research, 2, 27 - 40
Keijsers, G.P.J., Kampman, M., & Hoogduin, C.A.L. (2001). Dropout prediction in cognitive
behaviour therapy for panic disorder. Behavior Therapy, 32, 739-749.

Lebow, J. (1982). Consumer satisfaction with mental health treatment. Psychological
Bulletin, 91, 244-259.
Lowry, J.L., & Ross, M.J. (1997). Expectations of psychotherapy duration: How long should
psychotherapy last? Psychotherapy, 34, 272-277.
Maguire, M.C. (1999). Treating the dyad as the unit of analysis: A primer on three analytic
approaches. Journal of Marriage and the Family, 61, 213-223.
Manfred-Gilham, J.J., Sales, E., & Koeske, G. (2002). Therapist and case manager
perceptions of client barriers to treatment participation and use of engagement
strategies. Community Mental Health Journal, 38, 213-221.
Mueller, M., & Pekarik, G. (2000). Treatment duration prediction: Client accuracy and its
relationship to dropout, outcome, and satisfaction. Psychotherapy, 37, 117-123.
Nguyen, T.D., Attkisson, C.C., & Stegner, B.L. (1983). Assessment of patient satisfaction:
Development and refinement of a service evaluation questionnaire. Evaluation and
Program Planning, 6, 299-314.
Ogrodniczuk, J.S., Joyce, A.S., & Piper, W.E. (2005). Strategies for reducing patient-
initiated premature termination of psychotherapy. Harvard Review of Psychiatry, 13,
57-70.
Pekarik, G. (1983). Improvement in clients who have given different reasons for dropping
Pekarik, G. (1985a). Coping with dropouts. Professional Psychology: Research and
Practice, 16, 114-123.
Pekarik, G. (1985b). The effects of employing different termination classification criteria in
dropout research. Psychotherapy, 22, 86-91.

Pekarik, G. (1986). The use of treatment termination status and treatment duration patterns as
an indicator of clinical improvement. Evaluation and Program Planning, 9, 25-30.
Pekarik, G. (1991). Relationship of expected and actual treatment duration for adult and
child clients. Journal of Clinical Child Psychology, 20, 121-125.
Pekarik, G., & Wierzbicki, M. (1986). The relationship between clients’ expected and actual
treatment duration. Psychotherapy, 23, 532-534.
Prinz, R.J., & Miller, G.E. (1994). Family-based treatment for childhood antisocial
behaviour: Experimental influences on dropout and engagement. Journal of Consulting
and Clinical Psychology, 62, 645-650.
Pulford, J., Adams, P., & Sheridan, J. (2008). Therapist attitudes and beliefs relevant to client
dropout revisited. Community Mental Health Journal, 44, 181-186.
Raudenbush, S. W. Bryk, A. S. (2002). Hierarchical linear models: Applications and data
analysis methods. 2nd edition. Newbury Park, CA: Sage.
Reis, B.F., & Brown, L.G. (1999). Reducing psychotherapy dropouts: Maximizing
perspective convergence in the psychotherapy dyad. Psychotherapy, 36, 123-136.

Reis, B.F., & Brown, L.G. (2006). Preventing therapy dropout in the real world: The clinical
utility of videotape preparation and client estimate of treatment duration. Professional
Psychology: Research and Practice, 37, 311-316.
Richmond, R. (1992). Discriminating variables among psychotherapy dropouts from a
psychological training clinic. Professional Psychology: Research and Practice, 23,
123-130.
Rosen, C.S., Drescher, K.D., Moos, R.D., Finney, J.W., Murphy, R.T., & Gusman, F. (2000).
Six and ten item indices of psychological distress based on the Symptom Checklist-90.
Assessment, 7, 103-111.
Saatsi, S., Hardy, G.E., & Cahill, J. (2007). Predictors of outcome and completion status in
cognitive therapy for depression. Psychotherapy Reseasrch, 17, 185-195.
Saltzman, C., Luetgert, M.J., Roth, C.H., Creaser, J., & Howard, L. (1976). Formation of a
therapeutic relationship: Experiences during the initial phase of psychotherapy as
predictors of treatment duration and outcome. Journal of Consulting and Clinical
Sayer, A.G., & Klute, M. M. (2005). Analyzing couples and families: Multilevel methods.
Pp. 289-313. In Bengston, V.L., Acock, A.C., Allen, K.R., Dilworth-Anderson, P., &
Klein, D.M. (Eds). Sourcebook of family theory and research. (pp. 289-313). Sage
Publications.
Scamardo, M., Bobele, M., & Biever, J.L. (2004). A new perspective on client dropouts.
Journal of Systemic Therapies, 23, 27-38.
Smith, K.J., Subich, L.M., & Kalodner, C. (1995). The transtheoretical model’s stages and
processes of change and their relation to premature termination. Journal of Counseling
Statistics Canada (2001a). Income statistics for Ottawa-Hull. Retrieved July 26, 2003, from
Statistics Canada 2001 Community Profiles Online:
http://www12.statcan.ca/english/profil01/Details/details1inc2.cfm?SEARCH=BEGINS
&PSGC=35&SGC=35505&A=&LANG=E&Province=35&PlaceName=ottawa&CSD
NAME=Ottawa%20%2D%20Hull%CMA=&SEARCH=BEGINS&DataType=1&Typ
eNameE=Census%20Metropolitan%20Area&ID=805
Statistics Canada (2001b). Population statistics for Ottawa-Hull. Retrieved July 26, 2003,
from Statistics Canada 2001 Community Profiles Online:
http://www12.statcan.ca/enlish/profil01/Details/details1pop2.cfm?SEARCH=BEGINS
NAME=Ottawa%20%2D%20Hull&CMA=&SEARCH=BEGINS&DataType=1&Type
NameE=Census%20Metropolitan%20Area&ID=805
Swift, J.K., & Callahan, J.L. (2008). A delay discounting measure of great expectations and
the effectiveness of psychotherapy. Professional Psychology: Research and Practice,
39, 581-588.
Swift, J.K., Callahan, J.L., & Levine, J.C. (2009). Using clinically significant change to
identify premature termination. Psychotherapy: Theory, Research, Practice, Training,
46, 328-335.
Tracey, T.R. (1986). Interactional correlates of premature termination. Journal of Consulting
Tracey, T.J., & Kokotovic, A.M. (1989). Factor structure of the working alliance inventory.
Psychological Assessment, 1, 207-210.
Tryon, G., Blackwell, S., & Hammel, E. (2007). A meta-analytic examination of client-
therapist perspectives of the working alliance. Psychotherapy Research, 17, 629-642.
Tryon, G.S., & Kane, A.S. (1993). Relationship of working alliance to mutual and unilateral
termination. Journal of Counseling Psychology, 40, 33-36.
Walitzer, K.S., Dermen, K.H., & Conners, G.J. (1999). Strategies for preparing clients for
treatment: A review. Behavior Modification, 23, 129-151.
Weerasekera, P., Linder, B., Greenberg, L., Watson, J. (2001). The working alliance in
client-centered and process-experiential therapy of depression. Psychotherapy
Research, 11, 221-233.
Weiss, I., Rabinowitz, J. & Spiro, S. (1996). Agreement between therapists and clients in
evaluating therapy and its outcomes: Literature review. Administration and Policy in
Mental Health, 23, 493-511.

Zwick, R., & Attkisson, C.C. (1985). Effectiveness of a client pretherapy orientation
videotape. Journal of Counseling Psychology, 32, 514-524.

Footnotes
Hierarchical linear modeling (HLM; Maguire, 1999; Raudenbush & Bryk, 2002) was
also used to analyze hypotheses concerning the working alliance and barriers to treatment
participation. Results identical to those found with the repeated measures ANOVAs were
obtained. Therefore, we chose to report the more commonly understood general linear
modeling approach.
Table 4
Means and Standard Deviations of Client and Therapist Ratings of the Importance of
Termination Reasons.
Reason for Termination Client Client Therapist Therapist
Mutual Unilateral Mutual Unilateral
Accomplished goals 3.2 (1.2)a 2.2 (1.1)b 3.1 (1.1)1 1.6 (0.9)2
Could no longer fit time or 1.1 (0.6)a 2.1 (1.2)b 1.3 (0.6)1 2.5 (1.3)2
therapy into schedule
Just lost interest in therapy 1.1 (0.4)a 1.8 (1.2)b 1.2 (0.5)1 2.1 (1.0)2
No longer had money or 1.1 (0.6)a 1.8 (1.2)b 1.1 (0.3) 1.4 (1.0)
insurance coverage
Felt therapy was going 1.0 (0.3)a 2.5 (1.2)b 1.1 (0.4)1 1.6 (1.1)2
nowhere so ended therapy
Felt therapy was making 1.0 (0.2)a 1.8 (1.3)b 1.1 (0.3) 1.5 (1.1)
things worse
Weren’t confident in 1.1 (0.3)a 2.2 (1.3)b 1.1 (0.4)1 1.7 (1.0)2
therapist’s ability to help
Uncomfortable talking 1.0 (0.2)a 1.9 (1.2)b 1.1 (0.3)1 1.6 (1.0)2
about personal matters
Therapy did not fit with 1.2 (0.5)a 2.1 (1.2)b 1.2 (0.6) 1.6 (1.0)
ideas of what would be
helpful
Decided to go elsewhere 1.3 (0.9) 1.5 (0.8) 1.3 (1.0) 1.5 (1.0)
for services
Note. Within clients, columns with different superscript letters differed from each other at
least at p<.005. Within therapists, columns with different superscript numbers differed from
each other at least at p<.005

Table 5
Difference Scores and Standard Deviations (Client Importance Ratings Minus Therapist
Importance Ratings) of Reasons for Termination.
Reason for Termination Unilateral Mutual
n = 29 n = 52
Accomplished goals 0.6 (1.2) 0.1 (0.9)
Could no longer fit time or therapy into -0.3 (1.4) -0.1 (0.5)
schedule
Just lost interest in therapy -0.3 (1.4) -0.0 (0.4)
No longer had money or insurance coverage 0.3 (1.0) 0.1 (0.6)
Felt therapy was going nowhere so ended 0.9 (1.4)*a -0.0 (0.3)b
therapy
Felt therapy was making things worse 0.4 (1.1)a -0.0 (0.3)b
Weren’t confident in therapist’s ability to help 0.6 (1.4)a -0.0 (0.5)b
Uncomfortable talking about personal matters 0.3 (1.4) -0.1 (0.3)
Therapy did not fit with ideas of what would be 0.6 (1.4)a -0.1 (0.6)b
helpful
Decided to go elsewhere for services -0.1 (1.2) 0.0 (0.7)
*p<.001 indicate significant differences from zero.
Note. Columns with different superscripts differed from each other at least at p<.005
CHAPTER 4
Psychologists’ Perspectives on Therapy Termination and the Use of Therapy
Engagement Strategies
Robin Westmacott and John Hunsley
University of Ottawa
Abstract
Canadian psychologists (N = 269) were surveyed regarding their perspectives on client
reasons for termination at different points in therapy and their use of strategies to engage and
retain clients in therapy. Psychologists reported that one-third of their caseload unilaterally
terminated and assigned differential importance to termination reasons depending on whether
termination was before versus after the third session. Psychologists’ theoretical orientation
(CBT versus other) was not associated with their views of reasons for termination, but was
associated with their use of some engagement strategies. Despite these differences, all
psychologists reported at least occasional use of most engagement strategies. Future research
should examine psychologists’ perspectives on and barriers to using these strategies, along
with comparative effects of their addition to different forms of therapy and different client
problems.
Psychologists’ Perspectives on Therapy Termination and the Use of Therapy Engagement
Strategies
Five decades of research on client psychotherapy attrition does not appear to have
been translated into consistently reduced rates of client dropout in clinical practice (Barrett,
Chua, Crits-Cristoph, Gibbons, & Thompson, 2008; Swift, Levine, & Callahan, 2009).
Clients in routine practice settings attend a median of three to five sessions (e.g., Hansen,
Lambert, & Forman, 2002), much lower than the 13 to 18 sessions that dose-response studies
have repeatedly shown are necessary to achieve clinically significant change for the majority
of clients (Hansen et al., 2002; Howard, Kopta, Krause, & Orlinsky, 1986). The reasons for
clients’ attending so few sessions has been researched for some time, however the extent to
which therapists are aware of this research and modify their practices in order to address
relevant issues is less well-known. Knowledge of effective methods that therapists can
employ to engage and retain clients in therapy is also limited (Barrett et al., 2008). The
present study was designed to provide information about psychologists’ perspectives of
reasons for their clients’ termination, and the strategies psychologists use to engage and
appropriately retain their clients in therapy.
Numerous studies have examined clients’ reasons for ending therapy (Bados,
Balaguer, & Saldana, 2007; Hunsley, Aubry, Vestervelt, & Vito, 1999; Hynan, 1990;
Pekarik, 1992; Renk & Dinger, 2002; Roe, Dekel, Harel, & Fennig, 2006; Todd, Deane, &
Bragdon, 2003; Westmacott & Hunsley, 2010; Westmacott, Hunsley, Best, Rumstein-
McKean, & Schindler, 2010). Broadly, the reasons emphasized in this research generally
reflect a) goal attainment or substantial improvement in therapy, b) client-centered reasons

(demographic or psychological characteristics of the client, or dynamic factors such as
insufficient motivation), c) therapist or therapy-centered reasons (such as perceptions of
therapist incompetence or dislike of therapist or therapy), and d) circumstantial barriers (such
as scheduling conflicts or difficulties in paying for treatment). Clients who make unilateral
decisions to end therapy, compared with clients who make such a decision together with their
therapists (i.e., mutual terminators), are more likely to meet criteria for a mental disorder,
and therefore, are in greater need of services (Kazdin, Mazurik, & Siegel, 1994; Westmacott
& Hunsley, 2010), tend to be less satisfied with services (Lebow, 1982), and are less likely to
have improved (Pekarik, 1986; Prinz & Miller, 1994; Saatsi, Hardy, & Cahill, 2007).
Compared with mutual terminators, they are less likely to report leaving because they
accomplished their goals in therapy, and are more likely to report leaving therapy for reasons
such as feeling that therapy was going nowhere, a lack of confidence in their therapist’s
ability to help, or circumstantial barriers (e.g., Westmacott et al., 2010).
Reasons for Early versus Later Unilateral Termination
As all therapists know, some clients seek services but do not engage in therapy, other
clients engage in therapy but then make unilateral decisions to end therapy earlier than
therapists deem appropriate, and still other clients engage in treatment and make mutual
decisions with therapists to terminate. There is some evidence to suggest that there are
factors that are causally linked to early unilateral termination: failure on the part of the
therapist to return calls within a short time period (i.e., more than one day; Saporito, Barrett,
McCarthy, Iacoviello, & Barber, 2003), extended time on the waiting list (Festinger, Lamb,
Marlowe, & Kirby, 2002; Manthei, 1996; Stasiewicz & Stalker, 1999), first impressions of
therapists (Alcázar Olán, Deffenbacher, Hernández Guzmán, Sharma, & de la Chaussée

Acuña, 2010; Beckham, 1992;), support staff and clinic facilities (Chua & Barrett, 2007;
Gunzburger, Henggeler, & Watson, 1985), satisfaction with the intake session (Kokotovic &
Tracey, 1987), costs associated with therapy (Manthei, 1996), circumstantial barriers
(Hynan, 1990; Manthei, 1996), and a longer wait time from intake to first treatment session
(Rodolfa, Rapaport, & Lee, 1983). Evidence suggests that individuals who drop out before
attending any therapy, or who terminate after attending one or two sessions, are a
heterogeneous group and further investigation is required to determine the different reasons
why some people choose not to follow through with services. It is clear, however, that many
clients who terminate before engaging in therapy do not do so because their problems have
resolved. Given that client reasons for termination may vary at different points in the therapy
process, therapists’ understanding of the processes contributing to early termination is likely
to be inaccurate if researchers examine unilateral terminators as a homogeneous group
(Barrett et al., 2008; Kokotovic & Tracey, 1987). Accordingly, the present study was
designed to examine reasons for termination separately for clients who unilaterally end
therapy before attending three sessions (i.e., nonengagers) versus for clients who more fully
engage in the therapy process but end their treatments unilaterally. The third session was
chosen as a practical cut-off because of its identification as an important milestone in the
psychotherapy literature. Specifically, quality of the working alliance is established within
three sessions (Eaton, Abeles, & Gutfreund, 1988), and follow-up studies have shown that
clients attending one or two sessions of therapy tend to become worse, improve less, or
become more symptomatic (depending on the measure) than clients attending three or more
sessions (Pekarik, 1983a, 1983b, 1992).
Therapists Perspectives of Client Reasons for Termination

Therapist awareness of the extent of client unilateral termination is, presumably, a
motivating factor to take action, when appropriate, to actively engage and retain clients in
therapy. Unfortunately, research shows that therapists significantly underestimate the
proportion of unilateral terminators in their practices (Pekarik & Finney-Owen, 1987;
Pulford, Adams, & Sheridan, 2008), perhaps as a result of spending much of their time with
longer-term clients (Pekarik & Finney-Owen, 1987; Vessey, Howard, Lueger, Kächele, &
Margenthaler, 1994). Together with awareness of the prevalence of unilateral termination,
understanding clients’ reasons for leaving is a prerequisite for taking appropriate action. For
example, therapists who are aware that many clients end their treatments because they are
dissatisfied may be more likely to actively elicit and address clients’ negative perceptions
and to create a therapeutic atmosphere in which clients feel comfortable expressing negative
concerns.
Some researchers have investigated therapists’ perspectives of client reasons for
termination (Hunsley, Aubry, Vestervelt, & Vito, 1999; Murdock, Edwards, & Murdock,
2010; Pekarik & Finney-Owen, 1987; Renk & Dinger, 2002; Roe, Dekel, Harel, & Fennig,
2006; Todd, Deane, & Bragdon, 2003; Westmacott et al., 2010). Researchers who have
compared client and therapist reasons for termination have found that therapists and clients
tend to agree about reasons related to improvement in therapy and circumstantial barriers,
however, clients’ negative perceptions of therapy often go unnoticed by therapists, or are
attributed to clients’ low motivation or lack of time (Hunsley et al., 1999; Pekarik & Finney-
Owen, 1987; Todd et al., 2003). Furthermore, therapists appear to have greater difficulty
identifying reasons for clients’ unilateral decisions to end therapy than they do for mutual
decisions to end treatment. This is likely due, in large part, to being involved in such a
decision with mutual, but not unilateral, terminators. Nevertheless, in the context of
unilateral termination, therapists tend to underestimate clients’ negative perceptions of both
therapy and therapist, and clients’ perceptions of their goal attainment (Hunsley et al., 1999;
Westmacott et al, 2010). Therapists may underestimate clients’ positive therapy gains due to
differences in expectations and because clients may not reveal all positive changes, and
therapists may be unable to fully appreciate negative reactions in treatment because clients
often hide these feelings (e.g., Hill, Thompson, Cogar, & Denman, 1993; Hannan et al.,
2005; Regan & Hill, 1992).
Attributional biases may also interfere with therapists fully recognizing their roles in
unilateral termination (Campbell & Sedikides, 1999; Kendall et al., 1992; Malle, 2006;
Murdock, Edwards, & Murdock, 2010). Murdock et al. (2010) presented 243 psychologists
with two case study vignettes describing client unilateral termination that varied only in
whether the client was referred to as “your client” or “the client”. Their results suggested a
self-serving bias among psychologists’ responses, with participants showing a tendency to
blame the therapist when the vignette was “the client” and showing a tendency to blame the
client in the “your client” condition. The size of the self-serving bias was larger for male
therapists than for female therapists, and larger for psychodynamic therapists than for CBT
or existential/interpersonal therapists. Cognitive-behavioral therapists did not have different
attributions for termination in the two client conditions. It may be that cognitive-behavioral
therapists’ training emphasizing environmental influences on behavior partially mitigates
natural tendencies toward the fundamental attribution error. In another study, Kendall et al.
(1992) asked 315 experienced therapists about specific clients who had failed to benefit from
therapy. Therapists cited their clients’ inability to benefit from and lack of motivation for
treatment as the most important reasons for lack of progress, although rating themselves as
the least likely cause of their clients’ lack of progress. Theoretical orientation influenced
therapist perspectives: cognitive-behavioral therapists attributed significantly less
responsibility to the client compared to attributions made by psychodynamic, humanistic,
and eclectic therapists. In addition to examining therapists’ perspectives of client reasons for
termination early versus later in therapy, the present study is designed to shed light on how
theoretical orientation may influence therapists’ perspectives on client reasons for
termination.
Therapist Behaviors that Foster Mutual Decisions to End Psychotherapy
There is an important literature on the types of strategies that therapists can use to
increase engagement and reduce unilateral termination. Barrett et al. (2008), Ogrodniczuk,
Joyce, and Piper, (2005), and Walitzer, Dermen, and Connors, (1999), have conducted
comprehensive reviews of this literature and have identified the following strategies as
having some empirical support: Preceding therapy, clinicians can select clients most suitable
for a particular treatment (Baumann et al., 2001; Keijsers et al., 1999), set time limits on
treatment (Sledge et al., 1993), and engage the client in pretreatment preparation.
Pretreatment preparation can include role induction (educating clients about the rationale for,
process of, and prognosis for treatment), vicarious therapy pretraining (providing clients with
examples of therapy, such as videos), and experiential pretraining (engaging clients in a
simulation of therapy that is typically conducted in a group therapy context; Walitzer et al.,
1999). Engagement strategies that can be used throughout treatment include case
management (providing support to the client regarding life circumstances that may preclude
participation in therapy; Miranda, Azocar, Organista, Dwyer, & Arean, 2003), appointment
reminders, motivation enhancement (Carroll, Libby, Sheehan, & Hyland, 2001; Joe,
Simpson, Greener, & Rowan-Szal, 1999; Prochaska & DiClemente, 1982; Prochaska,
DiClemente, & Norcross, 1992), facilitation of therapeutic alliance (Tryon & Kane, 1993),
facilitation of affect expression (Bernard & Drob, 1989), and systematic monitoring of client
progress (Castonguay et al., 2004; Lambert, Harmon, Slade, Whipple, & Hawkins, 2005;
Safran, Muran, Samstag, & Stevens, 2002; Whipple, Lambert, Vermeersch, Smart, Nielsen,
& Hawkins, 2003).
No research, to our knowledge, has been conducted regarding whether therapists
explicitly employ these engagement strategies in routine practice. Furthermore, it is also
unclear whether therapeutic orientation serves to guide therapists in their use of these
strategies. Given that cognitive-behavioral therapy (CBT), compared with psychodynamic,
interpersonal, and humanistic therapies, is likely to be a more structured, time-limited,
circumscribed intervention (Blagys & Hilsenroth, 2002), CBT practitioners may be more
inclined than others to use these strategies (i.e., appointment reminders, case management,
setting a time limit on the number of therapy sessions, and systematic client monitoring).
Traditionally, other approaches are more centrally focused on the role of the therapeutic
relationship in the treatment process and, as such, may lead therapists using these other
orientations to focus more on building the early working alliance than on utilizing other
engagement strategies. These speculations remain untested, and the present study is designed
to shed light on this issue.
The Present Study and Hypotheses
In summary, unilateral terminators may have different reasons for early versus later
termination. Therapists’ perspectives of clients’ reasons for terminating early versus later in
the treatment process have not been explored. Understanding therapist perspectives is
essential to understanding processes related to clients’ choosing not to engage in therapy and
making unilateral decisions to end therapy once it has been initiated. Therapists’ awareness
of the frequency of unilateral termination, their perspectives of client reasons for terminating,
and their theoretical orientation may all influence the actions that therapists take to engage
and retain clients in therapy. Although several researchers have demonstrated the
effectiveness of some of these strategies, no study, to our knowledge, has been conducted to
examine their use in routine practice.
Our goal in the present study was to examine practicing psychologists’ perspectives
of reasons for termination for their clients who a) unilaterally terminated therapy before the
third session, b) unilaterally terminated after attending at least three sessions, and, c)
mutually terminated therapy. A second study goal was to examine whether psychologists, in
routine practice, used empirically-based strategies to engage clients in therapy and reduce
unilateral termination. Several specific hypotheses were formulated:
1) Comparing clients who terminated mutually with the psychologist and clients who
terminated unilaterally (both before and after the third session), we predicted that
psychologists would assign higher importance to symptom improvement and less importance
to all other reasons.
2) We predicted that the importance assigned to reasons for early versus later unilateral
termination would differ. For clients who terminated before the third session, versus after the
third session, psychologists would assign higher importance to circumstantial barriers, clients
having to wait too long for services, and clients having initial negative impressions.
3) We predicted that theoretical orientation would influence psychologists’ perspectives
of reasons for unilateral termination. Psychologists reporting a CBT orientation, versus other
orientations, would ascribe less importance to reasons that attributed fault to the client for
both early and later unilateral terminators (i.e., insufficient motivation; clients were unable to
benefit).
4) We predicted that theoretical orientation would influence the frequency of
psychologists’ use of engagement strategies. Psychologists reporting a CBT orientation,
versus other orientations, would be more likely to use practical strategies such as
appointment reminders, case management, setting a time limit on the number of therapy
sessions, and systematic client monitoring.
Method
Participants
Psychologists and psychological associates (i.e., in some jurisdictions, those
registered at the masters level) who provided individual psychotherapy to adults were
recruited through several psychological organizations and regulatory bodies throughout
Canada1. A notification about the study was sent electronically to members of the clinical
section of the Canadian Psychological Association (CPA), the College of Psychologists of
Ontario, and the Ottawa Academy of Psychologists. A bulletin was posted in the electronic
newsletters of the Alberta Psychological Association and the Association of Psychologists of
Nova Scotia. Personalized email requests were sent by the first author to 1,365 members of
the Canadian Register of Health Service Providers in Psychology who were listed as
1
For simplicity, we refer to all participants as psychologists.
providing individual therapy to adults. A link to the survey was also posted on the CPA’s
online Recruit Research Participants Portal.
Procedure
Potential respondents were emailed a brief study description: “If you are a psychologist
or psychological associate in supervised or autonomous practice and you provide individual
psychotherapy to adults, we invite you to take 10 minutes to complete a survey examining
issues around client termination.” Clicking on the link to the web survey took participants to
an informed consent page where they either consented or rejected study participation based
on detailed informed consent guidelines. Participants were asked about the proportion of
clients in their own practices who terminated (a) before fully engaging in treatment (i.e., who
terminated before the third session; the third session was chosen because of its identification
as an important milestone in the psychotherapy literature, Eaton, Abeles, & Gutfreund, 1988;
Horvath & Symonds, 1991; Reis & Brown, 1999), (b) after the third session, but unilaterally,
or without agreement from the therapist, and, (c) mutually with the therapist. Participants
were asked to rate the importance of reasons for ending psychotherapy separately, for all
three types of terminators.
Participants were requested to provide their sex, age, whether they were registered with
a masters or doctoral degree, number of years in independent practice, average number of
individual psychotherapy clients per week, percentage of services provided to adults,
children, and adolescents, and their dominant theoretical orientation (cognitive-behavioral,
family systems, humanistic/experiential, interpersonal, psychodynamic, or other – please
specify). Research ethics board approval was obtained for the study.
Demographic Characteristics of the Sample. Four hundred and forty-six
psychologists consented to participate, but many of these individuals completed only the
informed consent before discontinuing their participation. Two hundred and seventy-four
psychologists provided complete responses. Data from participants who indicated that their
client base was entirely comprised of children (n = 1), or who indicated seeing zero clients
per week (n = 4) were removed before proceeding with further analyses, leaving 269
psychologists in the sample.
Two-hundred and seventeen participants (80.7%) were licensed on the basis of a
doctoral degree, and 35 (13.0%) on the basis of a masters degree. Seventeen participants
(6.3%) did not indicate their highest achieved academic degree. Two hundred and forty-one
participants (89.6%) were in independent practice, eleven psychologists (4.1%) were in
supervised practice at the time of the survey, and seventeen psychologists (6.3%) did not
indicate their practice status. Of the 241 psychologists in independent practice, the mean
number of years in practice was 16.4 (SD = 10.4), with a median of 16, and a range from 1 to
40 years.
The mean age of the 246 psychologists who provided this information (23 did not
provide age) was 49.8 years (SD = 11.1), with a range from 25 to 71. The sample was
comprised of 156 women (58.0%), 94 men (34.9%), and 19 participants (7.1%) who did not
report their gender. The survey was available in both English and French: 254 psychologists
(94.4%) completed the survey in English, and 15 (5.6%) completed the survey in French.
Psychologists reported treating a mean number of 14.6 therapy clients per week (SD = 8.7;
range = 2 – 50; mode = 10). Most psychologists reported a primary theoretical orientation
that was cognitive-behavioral (n = 124, 46.1%); other psychologists self-identified their

orientations as other (n = 64, 23.8%), humanistic/experiential (n = 24, 8.9%), psychodynamic
(n = 22; 8.2%), interpersonal (n = 17, 6.3%), and family systems (n = 2; 0.7%). Sixteen
psychologists (5.9%) did not report a theoretical orientation. Of the psychologists who
reported “other,” nearly all (87.5%) indicated that they used a combination of the specified
orientations. Psychologists’ practices comprised a mean percentage of 85.8% adults (SD =
20.8), 9.6% adolescents (SD = 14.3), and 4.9% child clients (SD = 11.2).
Measures
Reasons for Termination. Participants were asked to rate the importance (0 = not at
all important; 4 = very important) of ten reasons for termination. Reasons were drawn from
the termination literature (e.g., Canadian Community Health Survey Cycle 1.2, 2002;
Hunsley et al., 1999; Pekarik & Finney-Owen, 1987; Westmacott & Hunsley, 2010).
Psychologists were asked to rate the importance of reasons for clients who (a) unilaterally
ended treatment before the third session, (c) attended at least three sessions and terminated
unilaterally, and, (d) terminated mutually. The ten possible reasons for termination were: a)
Clients reached their goals or symptoms improved, b) Clients wanted to solve their problems
in another way, c) Clients were not ready to change or had insufficient motivation, d) Clients
were unable to benefit from therapy, e) Clients believed that therapy was not helping, f)
Clients disliked the treatment, g) Clients had to wait too long for services, h) Clients had
negative impressions of my office or staff, i) Clients could not afford to pay, and j) Clients
had circumstantial barriers such as transportation, childcare, or scheduling issues.
Psychologists were also provided with an other – please specify category.
Psychologists’ Use of Engagement Strategies. Participants were asked about their
current efforts to increase engagement and reduce unilateral termination in their practices.
Strategies were drawn from Ogrodniczuk et al.’s (2005) review of the literature on therapist
strategies to reduce unilateral termination, with the added strategy of client treatment
monitoring. Participants were requested to “Please rate the extent to which you use the
following strategies to increase engagement and reduce client unilateral termination in
general in your practice.” Participants rated their frequency of use, on a scale of 0 (never
use) to 4 (always use), of: a) client selection (either do not accept certain clients for therapy,
or stop providing services if services are not working), b) in-depth pre-therapy preparation
(i.e., prior to commencing therapy, teaching the client about the rationale for therapy, role
expectations, how treatment progresses, common misconceptions about psychotherapy, and
possible difficulties one may experience during therapy), c) being explicit about negotiating
an agreed upon treatment plan, d) setting a time limit on the number of therapy sessions, e)
using motivational enhancement (i.e., prior to beginning therapy, initiate procedures that
increase the client’s willingness to enter into and remain engaged in treatment), f) explicitly
fostering a strong working alliance early in treatment, g) using case management (i.e.,
provide practical support to the client regarding difficult life circumstances that may
preclude participation in therapy, (e.g., directly assisting the client with housing or
employment problems, planning a budget, etc.), h) using appointment reminders, i)
conducting systematic client monitoring (use of a periodic questionnaire or formal
monitoring tool to assess client progress), and j) other – please specify.
Results
In addition to testing our hypotheses, we conducted several descriptive analyses on
factors associated with the reported frequency of different types of client termination and the
use of engagement strategies. We present these analyses first, followed by analyses that
address our hypotheses.
Proportions of Clients who Terminated at Different Points in Therapy
Psychologists reported that the mean percentage of clients who terminated
unilaterally before the third session was 13.1% (SD = 12.7%; median = 10%; mode = 5%).
The mean percentage of clients who terminated unilaterally after the third session was 20.2%
(SD = 17.0%; median = 15%; mode = 10%). The mean percentage of mutual terminators was
66.8% (SD = 23.3%; median = 75%; mode = 80%). Nine psychologists (3.4%) reported that
none of their clients terminated before the third session, and a further 103 (summing to
42.3%) reported that 5% or fewer of their caseload terminated before the third session. Nine
psychologists (3.4%) reported that no clients unilaterally terminated therapy after the third
session, and a further 49 (summing to 22.0%) reported that 5% or fewer of their caseload
terminated unilaterally after the third session. There were 18 (6.8%) psychologists who
reported that fewer than 20% of their clients terminated mutually, however, the majority of
psychologists (n = 105; 40.2%) reported that 80% or more of their clients terminated
mutually.
Age, years in independent practice, and number of clients per week were not related
to the percentages of clients reported as terminating unilaterally before the third session,
unilaterally after the third session, or as being mutual terminators. Male psychologists (M =
23.5%, SD = 18.3%) reported a significantly greater percentage of clients terminating
unilaterally after the third session than did female psychologists (M = 17.3%, SD = 15.9%),
F (1, 245) = 6.99, p<.01, d = 0.36, and significantly fewer mutual terminators (M = 62.4%,
SD = 23.2%) than did female psychologists (M = 70.6%, SD = 22.4%), F (1, 246) = 7.54,
p<.01, d = 0.36. Male (M =14.4%, SD = 12.4%) and female psychologists (M = 11.8%, SD =
12.2%) did not significantly differ on the reported percentages of therapy nonengagers (i.e.,
those who terminated before the third session), F (1, 246), = 2.57, ns.
Perspectives of Reasons for Termination Within Client Groups
As seen in Table 6, psychologists’ rated multiple reasons as having some importance
to all types of termination decisions. Three one-way repeated measures MANOVAs were
conducted to examine differences in psychologists’ ratings of reasons for termination within
each category of termination. For clients who unilaterally terminated before the third session,
the test of within-subjects effects indicated that there were significant differences in
psychologists’ ratings across reasons, F (7.15, 1666.56) = 65.87, p<.001, !2=.220. We were
interested in examining reasons rated as most and least important. Psychologists rated Clients
were not ready to change, or had insufficient motivation (65.7% important or very
important) as higher in importance than any other reason (for all pairwise comparisons,
p<.0001), Clients had to wait too long for services (15.8%) and Clients had negative
impressions of my office or staff (9.5%) as lower in importance than any other reason (all
p<.0001). For clients who unilaterally terminated after the third session, there were
significant differences in psychologists’ ratings across reasons, F(6.25, 1481.52) = 107.59,
p<.001, !2= .312. Psychologists rated Clients reached their goals or symptoms improved
(54.8%) as higher in importance than any other reason (all p<.0001), and Clients had to wait
too long for services (8.2%) and Clients had negative impressions of my office or staff (7.8%)
as lower in importance than any other reason (all p<.001). In the case of mutual decisions to
terminate, there were also significant differences in psychologists’ ratings across reasons,
F(5.40, 1333.50) = 289.03, p<.001, !2=.539. Psychologists rated Clients reached their goals
or symptoms improved (97.0%) as higher in importance than any other reason (all p<.0001),
but also rated a number of other reasons as having some importance, e.g., Clients could not
afford to pay (27.0%).
Psychologists’ Use of Engagement Strategies
Virtually all psychologists (96.8%) indicated that they often or always explicitly
foster a strong working alliance early in treatment, whereas other strategies were reported
much less frequently. Explicitly negotiating an agreed upon treatment plan (74.3% often or
always use), and in-depth pre-therapy preparation (58.0% often or always use) were the next
most frequently reported strategies. Between thirty and forty percent of psychologists
reported often or always using motivational enhancement (38.7%), client selection (36.6%),
and systematic client monitoring (33.0%). Approximately a quarter of psychologists reported
frequent use of time-limited treatment (23.6%). Case management (19.3%) and appointment
reminders (17.8%)2 were the most infrequently endorsed strategies.
Age was significantly negatively associated with using engagement strategies in
general (r = -.19, p<.01). More specifically, older psychologist age was associated with less
frequent reported use of pre-therapy preparation (r = -.14, p<.05), explicitly negotiating an
agreed-upon treatment plan (r = -.25, p<.001), setting a time limit on treatment (r = -.14,
p<.05), motivational enhancement (r = -.14, p<.05), and case management (r = -.15, p<.05).
2
Psychologists were also provided an other-please specify in detail category to elaborate on engagement
strategies. Thirty-eight psychologists provided 49 strategies and 35 of these strategies (71.4%) could be
coded into one of the 9 existing response options for the survey question. Of the other statements, several
reflected (a) an encouragement to have clients comment on their experience of treatment and (b) the use the
use of follow-up calls when clients missed appointments. Given the infrequency of these responses, they
were not included in any planned statistical analyses.
Number of clients per week was negatively associated only with frequency of use of time-
limited treatment (r = -.20, p<.01). Setting the familywise # at .15 (see Tabachnick & Fidell,
2007), ANOVA indicated that female psychologists were more likely to focus on building
the early working alliance, F(1, 235) = 6.80, p<.01, !2=.028, and use an explicit treatment
plan than were male psychologists, F (1, 235) = 6.91, p<.01, !2=.029.
Perspectives of Reasons for Termination (Hypotheses 1 and 2)
As shown in Table 6, the importance of possible reasons for termination varied
according to the nature of the termination3. Several separate repeated measures analyses of
variance were conducted to examine differences in psychologists’ ratings of reasons across
the three types of client termination. Multivariate analyses were not conducted because
reasons for termination do not theoretically represent the same theme. To keep the
familywise alpha at .15, a Bonferroni correction was applied to the 10 tests and only F values
below p<.015 were deemed significant (this strategy was used for the remainder of analyses
in the present study). For tests in which the assumption of sphericity was violated, the
Huynh-Feldt statistic was interpreted, as it has been shown to be the most accurate estimate
(Tabachnick & Fidell, 2007).
Insert Table 6 about here
3
A number of responses were given for the “other – please specify” category: 55 for the clients who
terminated prior to the third session, 26 for clients who terminated unilaterally after the third session, and 23
for clients who terminated mutually. The majority of these responses were simply elaborations of the other
ten response options available for the survey questions (i.e., 85.5% of responses for clients who terminated
prior to the third session, 84.6% for clients who terminated unilaterally after the third session, and 82.6% for
clients who terminated mutually). Of the responses that did not fit pre-existing categories, most of the
responses for the first two groups of clients reflected that the psychologist did not have clients who
terminated early or unilaterally, and most of the responses for the mutual termination clients reflected
termination due to institutional policies. Given the infrequency of these responses, they were not included in
any analyses on reported reasons for termination.
Psychologists assigned differential importance to all reasons across the three types of
terminators: Clients reached their goals or symptoms improved, F (1.79, 365.90) = 292.28,
p<.001, !2=.590 ; Clients wanted to solve their problems in another way, F (1.92, 393.36) =
28.96), p<.001, !2=.125; Clients were not ready to change, or had insufficient motivation, F
(1.88, 382.01) = 145.52, p<.001, !2=.418; Clients were unable to benefit from therapy, F
(1.83, 371.31) = 19.23, p <.001, !2=.087; Clients believed that therapy was not helping, F (2,
406) = 58.28, p<.001, !2=.223; Clients disliked the treatment, F(2, 406) = 59.18, p<.001,
!2=.226; Clients had to wait too long for services, F (1.51, 306.87) = 52.64, p<.001,
!2=.206; Clients had negative impressions of my office or staff, F (1.64, 332.03) = 34.01,
p<.001, !2=.144; Clients could not afford to pay, F (1.74, 355.63) = 47.15, p<.001, !2=.189;
Clients had circumstantial barriers such as transportation, childcare, or schedule issues,
F(1.96, 397.98) = 46.15, p<.001, !2=.185. Examination of pairwise comparisons indicated
that Hypothesis 1 was fully supported; psychologists assigned significantly higher
importance to Clients reached their goals or symptoms improved, and significantly lower
importance to all other reasons, when clients mutually versus unilaterally terminated (see
Table 6).
Hypothesis 2 was partially supported. As indicated in Table 6, the importance
psychologists assigned to reasons for early versus later unilateral termination differed. For
clients who terminated before versus after the third session, psychologists rated
circumstantial barriers, clients had to wait too long for services, and clients had negative
impressions of my office or staff as significantly more important. In addition, psychologists
also rated Clients were not ready to change, or had insufficient motivation, and Clients
disliked the treatment, as significantly more important for clients who unilaterally terminated
before versus after the third session, and significantly lower importance to Clients reached
their goals or symptoms improved.
Perspectives of Reasons for Termination: Impact of Theoretical Orientation
(Hypothesis 3)
One hundred and thirty-three psychologists who either indicated CBT as their
dominant theoretical orientation, or explicitly indicated one of cognitive, behavioral, or
cognitive-behavioral in combination with another orientation after selecting Other
orientation, were compared with 106 psychologists who did not explicitly indicate CBT as a
dominant approach (or as part of their response to Other orientation)4. Multiple between-
subjects analyses of variance were conducted to examine differences in CBT vs. other
psychologists’ ratings of reasons for unilateral (before vs. after the third session) termination.
CBT versus psychologists of other dominant orientations differed only on the importance
assigned to Clients could not afford to pay, F (1, 201) = 12.22, p<.001, !2= .057, given as a
reason for termination before the third session. CBT psychologists rated as significantly less
important Clients could not afford to pay (M = 1.9, SD = 1.6) vs. other orientations (M = 2.7,
SD = 1.3) p<.001, d = 0.6. Psychologists with CBT versus other orientations did not rate
other reasons for unilateral termination before the third session differently: Clients reached
their goals or symptoms improved, F (1, 201) = 0.47, ns; Clients wanted to solve their
problems in another way, F (1, 201) = 1.91, ns; Clients were not ready to change or had
insufficient motivation, F (1, 201) = 0.58, ns; Clients were unable to benefit from therapy, F
!
"Analyses were also conducted comparing only psychologists who explicitly selected CBT
as their dominant orientation with psychologists who explicitly selected another dominant
approach. Results were analogous.
(1, 201) = 0.48, ns; Clients believed that therapy not helping, F(1,201) = 0.30, ns; Clients
disliked the treatment, F(1,201) = 0.03, ns; Clients had to wait too long for services, F(1,
201) = 0.40, ns; Clients had negative impressions of my office or staff, F (1,201) = 2.56, ns;
Clients had circumstantial barriers such as transportation, childcare, or schedule issues,
F(1,201) = 1.89, ns.
In terms of reasons for unilateral termination after the third session, no significant
differences were found between psychologists reporting a CBT versus other orientation:
Clients reached their goals or symptoms improved, F (1, 201) = 0.34, ns; Clients wanted to
solve their problems in another way, F (1, 201) = 0.05, ns; Clients were not ready to change
or had insufficient motivation, F (1, 201) = 0.37, ns; Clients were unable to benefit from
therapy, F (1, 201) = 0.38, ns; Clients believed that therapy was not helping, F(1,201) =
0.85, ns; Clients disliked the treatment, F(1,201) = 0.15, ns; Clients had to wait too long for
services, F(1, 201) = 2.10, ns; Clients could not afford to pay, F(1,201) = 6.55, ns; Clients
had negative impressions of my office or staff, F (1,201) = 0.32, ns; Clients had
circumstantial barriers such as transportation, childcare, or schedule issues, F(1,201) =
4.19, ns.
Theoretical Orientation and Use of Engagement Strategies (Hypothesis 4)
Multiple between-subjects analyses of variance were conducted to examine
differences in CBT vs. other psychologists’ ratings of the frequency of use of engagement
strategies. Multivariate analyses were not conducted because strategies to retain clients in
therapy do not theoretically represent the same theme.
Insert Table 7 about here

As indicated in Table 7, the only strategies used differentially by cognitive-
behavioral psychologists were Systematic client monitoring, F(1, 236)=9.84, p<.01, !2=.040,
and Set a time limit on the number of therapy sessions, F(1, 236) = 6.04 p=.015, !2=.025.
CBT psychologists reported more frequent use of Systematic client monitoring (M = 2.1, SD
= 1.4) versus psychologists reporting other orientations (M = 1.6, SD = 1.3), d = 0.4, and Set
a time limit on the number of therapy sessions (CBT: M = 1.9, SD = 1.1; other: M = 1.5, SD
= 1.1), d = 0.4. CBT versus other psychologists did not significantly differ in frequency of
their use of other strategies: Client selection, F (1, 236) = .08, ns; In-depth pre-therapy
preparation, F(1,236) = 0.83, ns; Be explicit about negotiating and agreed upon treatment
plan, F(1,236) = 0.01, ns; Motivational enhancement, F(1,236) = 0.77, ns; Explicitly foster a
strong working alliance early in treatment, F(1,236) = 1.98, ns; Case management, F(1, 236)
= 0.04, ns; or Appointment reminders, F(1, 236) = 0.37, ns.
Discussion
The main purposes of this study were to examine (a) psychologists’ perspectives of
client termination from psychotherapy and (b) their self-reported use of engagement
strategies. Psychologists in this study reported that relatively few clients terminated
unilaterally before the third session (M = 13%). Although direct comparisons cannot be
made, consistent evidence from client data suggest that psychologists likely underestimated
the proportion of clients who terminated treatment very early. For example, the estimation of
13% is inconsistent with actual client data showing that 35% - 50% of clients completing an
intake do not attend the first therapy session (Garfield, 1986; Hansen et al., 2002; Phillips,
1985), and data showing that 40% of clients attend fewer than 3 sessions (Pekarik, 1983a).
Psychologists in this study reported that a mean of 20% of their clients unilaterally
terminated after the third session, summing to a combined unilateral termination rate of 33%.
This value is consistent with Pekarik and Finney-Owen (1987)’s sample of CMHC therapists
who estimated dropout rates in their overall clinics (32.8%). Pekarik and Finney-Owen also
collected clinic data for a portion of their therapist sample and found that although those
therapists estimated their own dropout rate to be 31.3%, the actual clinic dropout rate was
64.1% (based on 64 consecutive terminations). Pulford et al. (2008) replicated the Pekarik
and Finney-Owen study at an outpatient alcohol and drug treatment service, finding that
therapists estimated that 32% of their clients unilaterally terminated (their proxy dropout
measure was failure to attend a scheduled treatment session), although agency records
indicated the mean rate of this form of client unilateral termination was actually 65%.
Furthermore, the value of 33% reported by psychologists in Study 3 is low when compared
with meta-analytic data showing that 47% of clients prematurely terminate (Wierzbicki &
Pekarik, 1993). Although it is not possible to determine from Study 3 data without
corresponding data on actual unilateral termination, it is likely that psychologists
underestimated unilateral termination in their own practices, perhaps due to spending most of
their time with longer term, mutually terminating clients (Vessey et al., 1994). This is
problematic to the extent that psychologists take action to increase the likelihood appropriate
termination decisions as a function of recognizing that unilateral termination is a significant
problem.
Psychologists Perspectives of Clients’ Reasons for Termination
Unilateral termination. We examined psychologists’ perspectives of their clients’
reasons for making unilateral decisions to end treatment both early and later in therapy. As
seen in Table 7, at least 30% of psychologists rated several reasons for termination as
important or very important to clients’ decisions to leave either before or after the third
session, indicating that they perceived numerous reasons as potentially important to clients’
unilateral decisions to end therapy. Despite attributing importance to a range of reasons,
psychologists viewed insufficient motivation as the most important barrier to treatment
engagement. These results indicate that psychologists in this study viewed clients as
primarily responsible for failure to engage in treatment (Kendall et al., 1992). This view fits
with Lambert’s (1992) conclusion that up to 40% of the variance in outcome is attributable to
client variables and extratherapeutic factors, including but not limited to internal and external
factors such as social support, ego strength, psychological mindedness, and severity of
distress. Lack of readiness for change is undoubtedly a reason for unilateral termination for
some clients (e.g., Prochaska, Rossi, & Wilcox, 1991), regardless of whether or not
psychologists accurately detect the frequency of such clients (i.e., psychologists’ recall may
be biased because of being able to recall such clients with particular ease due to the
frustration they experienced with these unmotivated clients). A growing body of literature
documents the dynamic nature of client motivation for change, and the role of motivational
interviewing techniques in heightening client motivation (e.g., Arkowitz, Westra, Miller, &
Rollnick, 2007). Accordingly, the potential for using motivational enhancement strategies for
clients early in service provision seems as relevant now as it has been in the past.
For clients who terminated before versus after the third session, we expected that
psychologists would view circumstantial barriers, wait list time and negative initial
impressions as more important. Our hypotheses were supported in that psychologists rated
these reasons as relatively more important to early terminators. Small to moderate in

magnitude, these differences should be viewed in the context that, across unilateral
terminators, psychologists assigned the lowest importance of any reasons to the influence of
wait time and client negative impressions of clinic and staff. In contrast to research showing
that wait list length and negative impressions of office space or staff are important predictors
of engagement in therapy (e.g., Festinger et al., 2002; Stasiewicz & Stalker, 1999),
psychologists in this study did not view these factors as salient.
In addition to rating these reasons as particularly important for early terminators,
psychologists rated insufficient motivation, and clients disliking treatment as significantly
more important for clients who unilaterally terminated before versus after the third session.
Psychologists rated symptom improvement as significantly more important for late versus
early unilateral terminators. In fact, psychologists rated symptom improvement as the most
important reason for drop out after the third session. This finding runs counter to previous
conceptualizations of unilateral terminators as treatment failures (e.g., Garfield, 1986), and
adds to existing research showing that at least a portion of unilateral terminations experience
significant improvement in psychotherapy (Westmacott et al., 2010). In our view, it also
provides evidence that later unilateral terminators should not be studied together with early
unilateral terminators.
Mutual Termination. As hypothesized, when their clients made mutual decisions with
them to end services, psychologists viewed symptom improvement as most important, and
viewed all other reasons as far less important. As well, nearly 30% of psychologists rated as
important or very important to their mutual decisions to terminate that clients could not
afford to pay. In Canada, where the cost of psychological services often falls on consumers,
this finding is unsurprising. However, only 2% of clients interviewed in the Canada-wide

Canadian Community Health Survey (Cycle 1.2, 2003) provided this reason (Westmacott &
Hunsley, 2010). Approximately 20% of psychologists rated as important or very important
that clients left because they wanted to solve their problems in another way, that clients had
circumstantial barriers, and even that clients were not ready to change. These results indicate
that psychologists did not always view mutual termination as an unqualified success.
Theoretical Orientation
Given preliminary evidence that CBT therapists may be less vulnerable than other
therapists to the fundamental attribution error (i.e., attributing responsibility for failed
therapy to clients; Kendall et al., 1992; Murdock et al., 2010), we hypothesized that
theoretical orientation would influence psychologists’ perspectives of client reasons for
ending therapy. This hypothesis was not supported; theoretical orientation did not influence
psychologists’ perspectives of reasons for termination. Psychologists with CBT versus other
orientations assigned higher importance to financial constraints for clients who terminated
before versus after the third session. This was a small effect, and all other reasons were rated
equivalently by therapists of different theoretical orientations, including insufficient
motivation and clients being unable to benefit from therapy. This result provides evidence
that specific reasons for unilateral termination are viewed similarly across both CBT and
therapists of different theoretical orientations, perhaps reflecting increasing integration of
psychotherapies (Norcross & Goldfried, 2005).
Use of Engagement Strategies
Nearly all psychologists (96.8%) reported that they often or always focus on building
the early working alliance. Using an explicit treatment plan (74.3% often or always use), and
pre-therapy preparation (58.0% often or always use) were the next most frequently reported
strategies. Nearly 40% of psychologists reported the regular use of client selection and
motivational enhancement, and 33% of psychologists reported regular use of systematic
client monitoring. Less than a quarter of psychologists reported frequent use of time-limited
treatment, appointment reminders, or case management. Only one study is available for
limited comparison; Cook, Biyanova, Elhai, Schnurr, & Coyne (2010) surveyed 2,200
mental health practitioners (n = 374 psychologists) regarding what proportion of their clients
in the preceding month received each of 60 psychotherapy techniques. Eighty-six percent
reported that they focused on building the working alliance with most or all of their clients,
and 18% reported that they used case management on most or all of their clients. Although a
small effect, older psychologist age was associated with using over half of the engagement
strategies significantly less often. This may reflect differences in graduate training as
research demonstrating the effectiveness of engagement strategies continues to become more
prominent in research and teaching.
We hypothesized that theoretical orientation would influence psychologists’ choice of
engagement strategies. This hypothesis was partially supported; psychologists reporting a
CBT orientation reported more frequent use of systematic client monitoring, and time-
limited treatment. In contrast to hypotheses, CBT versus psychologists reporting other
orientations did not significantly differ in their use of appointment reminders and case
management. Overall, it appears as though engagement strategies largely transcended
theoretical orientation, and did not reflect theoretical or training differences given their
similar self-reported use across psychologists. However, it is possible that these conclusions
would not hold if use of engagement strategies were measured objectively (e.g., coding
videotaped therapy sessions). Furthermore, more focused research may reveal different
patterns of use of engagement strategies for different client problems. It would be
worthwhile for researchers to compare the additional utility of such engagement strategies
when used for specific types of client problems.
The low frequency of use of case management and appointment reminders is notable.
Clients with mental health problems often experience concurrent difficulty with practical life
problems. Sometimes these practical issues become barriers to proceeding with therapy.
Indeed, we have found that unilateral terminators perceive more barriers to treatment than do
mutual terminators, and that therapists are not aware of the extent of client barriers
(Westmacott et al., 2010). Given their ubiquity in medical and health-related professions, the
use of appointment reminders would seem a simple and easy strategy to implement (Turner
& Vernon, 1976). It would be worthwhile to examine psychologists’ views of the utility of
these strategies, as well as barriers to using them.
In summary, in this survey of Canadian psychologists regarding their perspectives on
client reasons for termination at different points in therapy and their use of strategies to
engage and retain clients in therapy, psychologists reported that one-third of their caseload
unilaterally terminated. They also assigned differential importance to termination reasons for
this depending on whether termination was before versus after the third session. Notably,
psychologists rated multiple reasons as having at least some importance to all clients’
decisions to leave therapy. Nevertheless, psychologists viewed lack of motivation as the
most important barrier to treatment engagement. Theoretical orientation (CBT versus other)
did not influence views of reasons for termination, but influenced use of engagement
strategies. Psychologists reporting a CBT orientation, compared to psychologists reporting
other orientations, reported more frequent use of time-limited treatment and systematic client
monitoring. Despite these differences, all psychologists reported at least occasional use of
most engagement strategies. Future research should examine psychologists’ perspectives on
and barriers to using these strategies, along with comparative effects of their addition to
different forms of therapy and different client problems.
Limitations
Although it was conducted with a relatively large group of psychologists recruited
from diverse locations in Canada, a limitation of this study is that exact generalizability is
unknown given the lack of data on nationally representative samples of psychologists. There
are larger American and international surveys of therapists across mental health professions
(Cook et al, 2010; Orlinksy, Botermans, & Ronnestad, 2001). In terms of Canadian
psychologists, no representative studies exist for comparison.
Nomothetic survey data of psychologists’ perspectives of their clients in general
cannot speak to how psychologists view reasons pertaining to specific clients, or how they
tailor their treatments and use of engagement strategies to specific clients. The method of
measuring reasons for termination and engagement strategies is also limited in that recall
biases may have prevented psychologists from accessing a proportionately accurate portrayal
of both their clients’ reasons for termination and their own use of engagement strategies. In
other words, self-reported practices might not accurately represent what psychologists
actually believe and do (Hoyt, 2002). This may be especially true for engagement strategies
such as the early working alliance, which has become a truism in the psychotherapy literature
(Watkins, 1997). Psychologists may vary in their conceptualizations about what building
early working alliance looks like in practice. More objective measures might include video
samples of random therapy sessions (as suggested by Cook et al., 2010) or real-time
sampling. It is also important to keep in mind that information on use of engagement
strategies does not endorse their effectiveness (Prochaska & Norcross, 1983). Furthermore,
as we have discussed previously (Westmacott & Hunsley, 2010), a more complete
understanding of termination is made possible by gathering parallel data from clients and
therapists (Cook et al, 2010; Westmacott et al., 2010). Despite these limitations, in order to
improve psychotherapy services, it is essential to be aware of how practicing psychologists’
perspectives generally fit with what is known about client termination and the present study
serves as a an important first step.

References
Alcázar Olán, R.J., Deffenbacher, J.L., Hernández Guzmán, L., Sharma, B., & de la
Chaussée Acuña, M.E. (2010). The impact of perceived therapist characteristics on
patients decision to return or not return for more sessions. International Journal of
Psychology and Psychological Therapy, 10, 415-426.
Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (Eds.; 2008). Motivational
Interviewing in the Treatment of Psychological Problems New York: Guilford Press.
Armbruster, P., & Kazdin, A.E. (1994). Attrition in child psychotherapy. Advances in
Clinical Child Psychology, 16, 81-108.
and the problem of drop-out. Journal of Clinical Psychology, 63(6), 585-592.
Barkham, M., Connell, J., Stiles, W.B., Miles, J.N.V., Margison, F., Evans, C., & Mellor-
Clark, J. (2006). Dose-effect relations and responsive regulation of treatment duration:
The good enough level. Journal of Consulting and Clinical Psychology, 74(1), 160-
167.
Barrett, M.S., Chua, W.J., Crits-Cristoph, P., Gibbons, M.B., Casiano, D., & Thompson, D.
(2008). Early withdrawal from mental health treatment: Implications for psychotherapy
practice. Psychotherapy Theory, Research, Practice, Training, 46(2), 247-267.
Barrett, M.S., Chua, W., & Thompson, D. (2007). Predicting dropout among women
receiving community-based mental health treatment. Paper presented at the annual
meeting of the Society for Psychotherapy Research, Madison, WI.
Baumann, B., Hilsenroth, M., Ackerman, S., Baity, M., Smith, C., Smith, S., Blagys, M.,
Price, J., Heindselman, T., Mount, M., & Holdwick, D. (2001). The Capacity for
Dynamic Process Scale (CDPS): An Examination of Reliability, Validity, and Relation
to Therapeutic Alliance. Psychotherapy Research, 11, 275-294.
Beckham, E.E. (1992). Predicting patient dropout in psychotherapy. Psychotherapy: Theory,
Research, Practice, Training, 29, 177-182.
Bernard, H.S., & Drob, S.L. (1989). Premature termination: A clinical study. Group, 13, 11-
22.
Blagys, M.D., & Hilsenroth, M.J. (2002). Distinctive activities of cognitive-behavioral
therapy: A review of the comparative psychotherapy process literature. Clinical
Psychology Review, 22, 671-706.
Cahill, J., Barkham, M., Hardy, G., Rees, A., Shapiro, D.A., Stiles, W.B., & Macaskill, N.
(2003). Outcomes of patients completing and not completing cognitive therapy for
depression. British Journal of Clinical Psychology, 42, 133-143.
in a training clinic. Psychological Services, 3, 129-136. Cohen, J. (1992). A power
primer. Psychological Bulletin, 112, 155-159.
Canadian Institutes for Health Information (2006) Retrieved February 15, 2010, from
http://secure.cihi.ca/cihiweb/products/Psychologists.pdf
Canadian Psychological Association (2009). Annual Report. Retrieved February 15, 2010,
http://www.cpa.ca/aboutcpa/annualreports/
Carroll, K.M., Libby, B., Sheehan, J., & Hyland, N. (2001). Motivational interviewing to
enhance treatment initiation in substance abusers: An effectiveness study. American
Journal on Addictions, 10, 335-339.

Castonguay, L.G., Schut, A.J., Aikins, D., Constantino, M.J., Laurenceau, J.P., Bologh, L., &
Burns, D.D. (2004). Integrative cognitive therapy for depression: A preliminary
investigation. Journal of Psychotherapy Integration, 14, 4-20.
Chua, W.J., & Barrett, M. (2007, October). The influence of physical environment on
engagement in psychotherapy. Paper presented at the annual meeting of the North
American Society for Psychotherapy Research, New York.
Cook, J.M., Biyanova, T., Elhai, J., Schnurr, P.P., & Coyne, J.C. (2010). What do
psychotherapists really do in practice? An internet study of over 2,000 practitioners.
Psychotherapy Theory, Research, Practice, Training, 47(2), 260-267.
Crits-Christoph, P., Connolly Gibbons, M.B., Crits-Cristoph, K., Narducci, J., Schamberger,
M., & Gallop, R. (2006). Can therapists be trained to improve their alliances? A
preliminary study of alliance-fostering psychotherapy. Psychotherapy Research, 16,
268-281.
Eaton, T.T., Abeles, N., & Gutfreund, M.J. (1988). Therapeutic alliance and outcome:
Impact of treatment length and pretreatment symptomatology. Psychotherapy, 25, 536-
542.
Festinger, D.S., Lamb, R.J., Marlow, D.B., & Kirby, K.C.(2002). From telephone to office:
Intake attendance as a function of appointment delay. Addictive Behaviors, 27, 131-
137.
Garb, H. N., & Boyle, P. A. (2003). Understanding why some clinicians use pseudoscientific
methods: Findings from research on clinical judgment. In S. O. Lilienfeld, S. J. Lynn,
& J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology (pp. 17-38).
New York: Guilford.

Garfield, S.D., (1986). Research on client variables in psychotherapy. In S.L. Garfield &
A.E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp/213-
256). New York: Wiley.
Garfield, S.L., (1994). Research on client variables in psychotherapy. In A.E. Bergin & S.L.
Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 190-228). New
York: Wiley.
Gunzburger, D.W., Henggeler, S.W., & Watson, S.M. (1985). Factors related to premature
termination of counseling relationships. Journal of College Student Personnel, 26, 456-
460.
Hannan, C., Lambert, M., Harmon, C., Nielson, S., Smart, D., Shimokawa, K., & Sutton,
S.W. (2005). A lab test and algorithms for identifying clients at risk for treatment
failure. Journal of Clinical Psychology, 61(2), 155-163.
Hansen, N.B., Lambert, M.J., Forman, E.M. (2002). The psychotherapy dose-response effect
and its implications for treatment delivery services. Clinical Psychology: Science and
Practice, 9(3), 329-343.
Hill, C.E., Thompson, B.J., Cogar, M.C., & Denman, C. (1993). Beneath the surface of long-
term therapy: Therapist and client report of their own and each other’s covert
processes. Journal of Counseling Psychology, 40(3), 28-287.
Horvath, A.O., & Symonds, B.D. (1991). Relation between working alliance and outcome in
psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139-149.
Howard, K.I,, Kopta, S.M., Krause, M.S., & Orlinsky, D.E. (1986). The dose-effect
relationship in psychotherapy. American Psychologist, 41(2), 159-164.

Hoyt, W.T. (2002). Bias in participant ratings of psychotherapy process: An initial
generalizability study. Journal of Counseling Psychology, 49(1), 35-46.
388.
Hynan, D.J. (1990). Client reasons and experiences in treatment that influence termination of
psychotherapy. Journal of Clinical Psychology, 46(6), 891-895.
Joe, G.W., Simpson, D.D., Greener, J.M., & Rowan-Szal, G.A. (1999). Integrative modeling
of client engagement and outcomes during the first 6 months of methadone treatment.
Addictive Behaviors, 24, 649-659.
Keijsers, G.P.J., Schaap, C.P.D.R., Hoogduin, C.A.L., Hoogsteyns, B., & de Kemp, E.C.M.
(1999). Preliminary results of a new instrument to assess patient motivation for
treatment in cognitive-behaviour therapy. Behaviour and Cognitive Psychotherapy, 27,
165-179.
16(3), 269-281.
Kokotovic, A.M., & Tracey, T.J. (1987). Premature termination at a university counseling
center. Journal of Counseling Psychology, 34(1), 80-82.
Kushner, M.G., Sher, K.J. (1989). Fear of psychological treatment and its relation to mental
health service avoidance. Professional Psychology: Research and Practice, 20, 251-
257.
Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative

and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of
psychotherapy integration (pp. 94-129). New York: Basic Books.
Lambert, M.J., Harmon, C., Slade, K., Whipple, J.L., & Hawkins (2005). Providing feedback
to psychotherapists on their patients’ progress: Clinical results and practice
suggestions. Journal of Clinical Psychology/In Session, 61(2), 165-174.
Lambert, M.J., & Ogles, B.M. (2004). The efficacy and effectiveness of psychotherapy. In
M.J., Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behaviour
change (5th ed)., pp. 139-193. New York: Wiley.
Lambert, M.J., Whipple, J.L., Hawkins, E.J., Vermeersch, D.A., Nielsen, S.L., & Smart,
D.W. (2003). Is it time for clinicians to routinely track patient outcome? A meta-
analysis. Clinical Psychology, Science and Practice, 10(3), 288-301.
Latour, D., & Cappeliez, P. (1994). Pretherapy training for group cognitive therapy with
depressed older adults. Canadian Journal of Aging, 13, 221-235.
Manthei, R.J. (1996). A follow-up study of clients who fail to begin counseling or terminate
after one session. International Journal for the Advancement of Counselling, 18, 115-
128.
Miranda, J., Azocar, F., Organista, K.C., Dwyer, E., & Arean, P. (2003). Treatment of
depression among impoverished primary care patients from ethnic minority groups.
Psychiatric Services, 54, 219-225.
relationship to dropout, outcome, and satisfaction. Psychotherapy, 37(2), 117-123.

Norcross, J.C., & Goldfried, M.R. (Eds). (2005). Handbook of Psychotherapy Integration.
Oxford University Press: New York.
Norcross,J.C., Karpiak, C.P., & Santoro, S.O. (2005). Clinical psychologists across the
years; the division of clinical psychology from 1960 to 2003. Journal of Clinical
Psychology, 61, 1467-1483.
Oei, T.P.S., & Kazmierczak, T. (1997). Factors associated with dropout in a group cognitive
behaviour therapy for mood disorders. Behavioral Therapy and Research, 11, 1025-
1030.
57-70.
Orlinsky, D.E., Botermans, J.F., & Ronnestad, M.H. (2001). Towards an empirically
grounded model of psychotherapy training : Four thousand therapists rate influences on
their development. Australian Psychology, 36(2), 139-148.
Pekarik, G. (1983a). Follow-up adjustment of outpatient dropouts. American Journal of
Orthopsychiatry, 53, 501-511.
Pekarik, G. (1983b). Improvement in clients who have given different reasons for dropping

Phillips, E.L. (1985). Psychotherapy revised: New frontiers in research and practice.
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more
integrative model of change. Psychotherapy: Theory, Research, & Practice, 19, 276-
288.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people
change: Applications to addictive behaviours. American Psychologist, 47, 1102-1114.
Prochaska, J.O., & Norcross, J.C. (1998). Contemporary psychotherapists: A national survey
of characteristics, practices, orientations, and attitudes. Psychotherapy: Theory,
Research and Practice, 20, 161-173.
Prochaska, J.O., Rossi, J.S., & Wilcox, N.S. (1991). Change processes and psychotherapy
outcome in integrative case research. Journal of Psychotherapy Integration, 1, 103-
120.
Regan, A.M., & Hill, C.E. (1992). Investigation of what clients and counsellors do not say in
brief therapy. Journal of Counseling Psychology, 39, 168-174.
Rodolfa, E.R., Rapaport, R., & Lee, V.E. (1983). Variables related to premature terminations
in a university counseling service. Journal of Counseling Psychology, 30, 87-90.

Rogers, C.P. (1951). Client-centered therapy. Boston: Houghton Mifflin.
Rumstein-McKean, O. (2005). Seeking and engaging in psychotherapy: Investigating the
comparative value of two models (Doctoral dissertation, University of Ottawa, 2005).
Safran, J.D., Muran, J.C., Samstag, L.W., & Stevens, C. (2002). Repairing alliance ruptures.
In J.C. Norcross (Ed.)., Psychotherapy relationships that work (pp. 235-254). New
York: Oxford University Press.
Saporito, J.M., Barrett, M.S., McCarthy, K.S., Iacoviello, B., & Barber, J.P. (2003, June).
Predicting failure to attend intake appointment. Paper presented at the annual meeting
of the Society for Psychotherapy Research, Weimar, Germany.
Sledge, W.H., Moras, K., Hartley, D., et al. (1990). Effect of time-limited psychotherapy on
patient dropout rates. American Journal of Psychiatry, 147, 1341-1347.
Sparks, W.A., Daniels, J.A., & Johnson, E. (2003). Relationship of referral source, race, and
wait time on preintake attrition. Professional Psychology: Research and Practice, 34,
514-518.
Stasiewicz, P.R., & Stalker, R. (1999). A comparison of three “interventions” on
pretreatment dropout rates in an outpatient substance abuse clinic. Addictive Behaviors,
24, 579-582.
Stewart, R.E., & Chambless, D.L. (2008). Treatment failures in private practice: How do
psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181.

46, 328-335.
Tabachnick, B.G., & Fidell, L.S. (2007). Experimental designs using ANOVA. Belmont, CA:
Thompson, Brooks, and Cole.
Vessey, J.T., Howard, K.I., Lueger, R.J., Kächele, H., & Margenthaler, E. (1994). The
clinician’s illusion and the psychotherapy practice: An application of stochastic
modeling. Journal of Consulting and Clinical Psychology, 62, 679-685.
Walitzer, K.S., Dermen, K.H., & Connors, G.J. (1999). Strategies for preparing clients for
treatment. Behavior Modification, 23, 239-252.
Watkins, C.E. (1997). Reflections on contemporary psychotherapy practice, research, and
training. Journal of Contemporary Psychotherapy, 27, 5-22.
Westmacott, R., & Hunsley, J. (2010). Reasons for terminating psychotherapy: A general
population study. Journal of Clinical Psychology, 66, 965-977.

Table 6
Psychologists’ Perspectives of the Importance of Reasons for Termination for Clients Who
Unilaterally Terminated Before the Third Session, After the Third Session, or Mutually
Terminated (Mean, Standard Deviation, and Proportion of Psychologists Reporting the
Reason as Important or Very Important to Clients’ Termination Decisions)
Before third After third session Mutual

session M (SD) M (SD)
M (SD)
% Important or % Important or Very % Important or

Very Important Important Very Important
a) Clients reached 1.8 (1.5)a 2.7 (1.2)b 3.8 (0.5)c

their goals or
symptoms 32.7 54.8 97.0
improved
b) Clients wanted to 2.1 (1.2)a 2.0 ( 1.2)a 1.4 (1.2)b

solve their
problems in 36.6 33.3 21.1
another way
c) Clients were not 2.8 (1.2)a 2.2 (1.2)b 1.3 (1.3)c

ready to change, or
had insufficient 65.7 41.5 18.4
motivation
d) Clients were 1.5 (1.2)a 1.6 (1.2)a 1.1 (1.3)b

unable to benefit
from therapy 22.4 25.5 16.5
e) Clients believed 2.0 (1.2)a 2.0 (1.2)a 1.2 (1.3)b

that therapy was
not helping 33.3 38.8 17.0
f) Clients disliked the 1.9 (1.2)a 1.7 (1.2)b 1.0 (1.3)c

treatment
31.4 25.3 14.3
g) Clients had to wait 1.0 (1.3)a 0.6 (1.0)b 0.4 (1.0)c

too long for
services 15.8 8.2 6.6
h) Clients had 0.9 (1.2)a 0.6 (1.0)b 0.4 (1.0)c

negative
impressions of my 9.5 7.8 5.0
office or staff
i) Clients could not 2.3 (1.5)a 2.2 (1.5)a 1.6 (1.4)b

afford to pay
48.1 47.3 27.0
j) Clients had 2.1 (1.2)a 1.9 (1.2)b 1.4 (1.2)c

circumstantial
barriers such as 37.9 33.5 18.5
transportation,
childcare, or
schedule issues
Note. Reasons were rated from 0 (Not At All Important) to 4 (Very Important). Within each
reason, column entries with different superscripts differ from each other at least at p<.01.
Table 7
Psychologists’ Use of Engagement Strategies: A Comparison Between Psychologists with a
CBT versus Other Orientation
Dominant CBT Other orientations
M (SD) M (SD)
Client selection 2.2 (1.1) 2.1 (1.0)
Pre-therapy preparation 2.6 (1.2) 2.5 (1.4)
Explicit treatment plan 3.0 (0.9) 3.1 (1.0)
1.9 (1.1)a 1.6 (1.1)b

Time-limited treatment
Motivational enhancement 2.0 (1.3) 1.9 (1.4)
Fostering early working alliance 3.7 (0.6) 3.8 (0.6)
Case management 1.6 (1.1) 1.5 (1.1)
Appointment reminders 1.4 (1.3) 1.2 (1.2)
Systematic client monitoring 2.1 (1.4)a 1.6 (1.3)b
Note. Engagement strategies were rated from 0 (Never Use) to 4 (Always Use). Column
entries with different superscripts differ from each other at least at p<.017.
CHAPTER 5
General Discussion
Introduction
This dissertation was designed to improve understanding of client reasons for
termination from adult psychotherapy from the perspectives of clients, trainees, and licensed
psychologists. A handful of researchers had examined reasons for termination, however, the
variability in treatment settings and small sample sizes rendered the generalizability of these
reasons uncertain. Therefore, in Study 1, I used national data from the Canadian Community
Health Survey (Cycle 1.2, 2003) to identify the prevalence and correlates of client reasons
for termination in an epidemiological survey. A more complete picture of termination results
from parallel consideration of client and therapist data, therefore, Study 2 was designed to
examine the congruence in perspectives of client-therapist dyads regarding reasons for
termination and other factors in therapy. Most researchers have surveyed trainees, and have
assessed unilateral termination in general as opposed to assessing reasons separately for
clients who leave early versus later in the therapy process. Therefore, Study 3 was designed
to examine psychologists’ perspectives of client reasons for termination at different points in
the therapy process. A second study goal was to examine the strategies psychologists used to
engage and retain clients in therapy. I will present and discuss the findings and limitations of
each study individually. Following this, I will discuss implications of this research for future
investigation and clinical practice.
Study 1: Reasons for Terminating Psychotherapy: A General Population Study

I examined clients’ self-reported reasons for ending psychotherapy and the
associations among specific termination reasons with demographic variables (age, gender,
income), mental disorder diagnoses (anxiety disorder, mood disorder, and substance
dependence) and mental health care service provider (social
worker/counselor/psychotherapist, psychologist, general practitioner, and psychiatrist).
Despite being given the opportunity to endorse multiple reasons, most respondents (85.1%)
chose to indicate only one reason for termination. Ending therapy because of feeling better,
the most frequently reported reason, was reported by almost half of respondents (43.4%).
This value is consistent with some clinic studies (44%, Hunsley et al., 1999; 45.5%, Roe et
al., 2006), but is substantially larger than the values reported in others (25% in Renk &
Dinger, 2002; 23.5% in Todd et al., 2003), underscoring the importance of using population-
based data to provide estimates broadly applicable to various settings and service providers.
You completed the recommended treatment was reported by far fewer respondents
(13.4%), potentially reflecting the limited number of therapeutic services in Canada that have
a predetermined set of sessions (i.e., limits set by third party payers). It was not helping was
endorsed by 14.1% of respondents, and the remainder of the termination reasons were each
reported by about 5% of respondents, with two exceptions. The low-frequency of the
response You were too embarrassed to see the professional (0.4%) may be due to the fact
that the experience of embarrassment surrounding psychotherapy may be a more salient issue
in decisions around treatment seeking and initial engagement rather than treatment
termination. The second low-frequency response, You had problems with things like
transportation, childcare, or your schedule (2.1%), was rated much lower than what would
be expected based on evidence from clinic studies: for example, 35% (Pekarik, 1983), 19.9%
(Renk & Dinger, 2002), 54.6% (Roe et al., 2006), and 53% (Todd et al., 2003). The inability
to overcome circumstantial barriers is undoubtedly an important reason that some people end
treatment. However, it may be that individuals provide this reason as an acceptable excuse,
and are more apt to provide honest reasons for termination to an anonymous interviewer
rather than clinic staff or research staff affiliated with the clinic where termination occurred.
Despite the prevalence of each of these reasons being low, taken together, results indicated
that at least 44.7% of respondents left psychotherapy due to some barrier to treatment,
preference for solving the problem on one’s own, or dissatisfaction with psychotherapy.
Demographic variables. Study 1 was the first population-based study to examine the
associations among specific reasons for terminating therapy with demographic variables,
mental disorder diagnoses, and mental health care provider. Overall, age and gender were not
associated with odds of selecting any reason for termination. Consistent with previous
research (Edlund et al., 2002; Wierzbicki & Pekarik, 1993; Williams, Ketring, & Salts,
2005), the socioeconomic status indicator low income was a predictor of untimely
termination from psychotherapy. Low income decreased the odds of termination due to
improvement and increased the odds of termination due to perception that therapy was not
helping.
Mental disorder caseness. In terms of clinical variables, meeting criteria for an
anxiety disorder, a mood disorder, or substance dependence decreased the odds of
termination due to feeling better. This finding is particularly troubling as individuals with
clinical disorders require the most help from psychotherapy and, based on the survey data,
they are less likely than those without diagnosable conditions to report that they received the
help that they needed to make improvements in their lives. Meeting criteria for 12-month
substance dependence doubled the odds of completing treatment. This could reflect the
typical practice of providing intensive time-limited treatment programs for substance abuse.
The lack of association with other predictor variables may be due to the heterogeneous
reasons underlying treatment having been completed, including the possibilities that
treatment completion may be largely determined by therapists and that the prescribed
number of sessions has only a limited relation to the clinical profile of clients.
Mental health service provider. In terms of mental health service provider, only
termination with a psychiatrist significantly affected odds of selecting two reasons for
termination. Individuals who terminated with psychiatrists had decreased odds of terminating
due to symptom improvement and increased odds of terminating due to perceiving therapy as
unhelpful. However, in the present study, there was evidence that, compared to other
professionals, psychiatrists treated more individuals with diagnosable conditions and, thus,
more severe psychopathology. This should be considered when interpreting this finding.
Aside from the data from former clients of psychiatrists, there were no differences in reasons
for termination across mental health professionals and general practitioners. Despite what are
likely sizeable differences in training, experience, and therapeutic approach, differences
across professions were not meaningfully related to reasons for termination.
Limitations. It is important to distinguish that this study examined reasons for
termination in general and not premature termination in particular. For example, feeling
better could be given as a reason for either unilateral or mutual decisions to terminate with
the therapist. Therefore, the results do not inform us about factors exclusively associated
with unilateral termination. External validity and generalizability of results was enhanced by
the broad sampling of clients, however, the data provided no information on the nature of
psychotherapy services provided. Type of psychotherapeutic treatment and therapist
competence influence reasons for termination; however, information on these important
factors was not included in the survey. The method of measuring reasons for termination is
inherently limited; respondents varied in the length of time passed between psychotherapy
termination and the administration of the survey, during which time recall biases may have
affected their responses. As well, individuals do not necessarily have conscious access to all
the reasons for their decisions, and a more complete picture of termination is possible when
therapist and client perspectives are simultaneously considered. Despite these inherent
limitations, it is essential for both researchers and therapists to be aware of clients’
understanding of their reasons for terminating psychotherapy.
Furthermore, the prevalence and predictors of reasons for termination in the present
study may not generalize to all health care systems. For example, Edlund et al. (2002),
comparing mental health treatment dropouts in Ontario, Canada, and the United States, found
no differences in proportion of dropouts, cumulative probability of dropping out, or effects of
various predictors. However, a lack of insurance coverage increased odds of dropping out in
the American dataset by 1.5. Lastly, the infrequency of some of the reasons for termination
affected plans to examine patterns of association existing in the data. All of these limitations
must be kept in mind when interpreting the results.
Summary. The most frequently reported reason for terminating therapy was that the
client felt better. This positive result is tempered by the recognition that less than half of
clients reported leaving psychotherapy due to this reason. Nearly half of respondents
reported leaving psychotherapy due to some barrier to or dislike of treatment, or because of

wanting to solve problems in a different manner. In general, individuals with low income and
diagnosable mental disorders had significantly increased odds of premature termination.
Study 2: Client and Therapist Views of Contextual Factors Related to Termination
from Psychotherapy: A Comparison between Unilateral and Mutual Terminators
In Study 2, I examined the congruence in perspectives of client-therapist dyads
regarding clients’ reasons for termination, working alliance, and barriers to treatment
between two groups where a) both client and therapist agreed that termination was a
unilateral decision on the client’s part, or b) both client and therapist agreed that termination
was mutual. As hypothesized, unilaterally terminating clients, compared with mutual
terminators, rated the importance of having accomplished their goals in therapy as less
important to their decision to end therapy, and reasons related to circumstantial barriers and
dislike of therapist and therapy as more important to their decision. Therapists reported a
similar pattern of results; therapists of unilateral terminators, compared with therapists of
mutual terminators, reported that their clients’ accomplishing goals in therapy was less
important to their decisions, and that reasons related to circumstantial barriers and dislike of
therapist and therapy were more important to their decisions.
Client-therapist perspective divergence. When client-therapist assessments were
examined within each dyad, small, but systematic differences in attributions of clients and
their therapists became evident. When termination decisions were mutual, there was no
difference between client and therapist ratings of the importance of any termination reason.
When clients terminated therapy unilaterally, compared with their therapists, they rated four
out of ten reasons for termination as significantly more important to their decision to leave.
They ascribed higher importance to all of the reasons related to dislike of therapy or
therapist: felt therapy was going nowhere so ended therapy, felt therapy was making things
worse, weren’t confident in therapist’s ability to help, and therapy did not fit with ideas
about what would be helpful. Clients and therapists rated the importance of more benign and
circumstantial barriers similarly.
Outcome data collected in the study also reflect a perspective divergence between
clients and therapists in the unilateral, but not the mutual, termination group; unilateral
terminators rated their distress as significantly lower at post-therapy whereas their therapists
indicated no change in functioning. In contrast, clients in the mutual termination group
reported a similar decline in distress from pre-therapy to post-therapy, and their therapists
agreed with them, reporting a significant increase in functioning.
These results build on previous research showing that therapists tend to perceive both
treatment success and failure differently than do clients (Hunsley et al., 1999; Pekarik &
Finney-Owen, 1987). Directly comparing client and therapist ratings, results from the present
study indicate that these differences in perception occur exclusively around unilateral
termination. When termination was a unilateral decision on the client’s part, therapists
appeared not to be aware of the extent to which clients’ perceived either success in therapy
(i.e., symptom improvement), or their dissatisfaction (i.e., felt therapy was going nowhere,
lack of confidence in therapist’s ability, lack of helpfulness). Given the small differences in
client and therapist ratings, it appears that therapists were largely aware of clients’
dissatisfaction, but tended to rate the importance of clients’ dissatisfaction reasons as less
important than they actually were. This could reflect both self-serving biases (whereby
therapists are not as likely to rate themselves too negatively) and differing expectations about
what will be accomplished in therapy. It likely also reflects the limited communication
inherent in unilateral decision-making; clients may be unlikely to share the extent of their
negative perceptions of therapy and the therapist.
Therapeutic alliance. In line with previous research, and as hypothesized, client-
therapist dyads that made mutual decisions to end therapy reported a stronger working
alliance early in treatment than did client-therapist dyads in which the client terminated
unilaterally. Contrary to my hypothesis that mutually terminating dyads would have more
similar perceptions of the working alliance, all clients rated the early alliance significantly
higher than did their therapists regardless of how they terminated therapy. The tendency for
clients to rate the alliance higher than their therapists is well-documented in the literature
(e.g., Bachelor & Salame, 2000; Fitzpatrick, Iwakabe, & Stalikas, 2005; Hersoug, Hoglend,
Monsen, & Havik, 2001; Hilsenroth, Peters, & Ackerman, 2004; Tryon et al., 2007), and
holds true in this study despite clients’ eventual unilateral decisions to leave, and poorer
therapeutic outcome. Although there has been no systematic investigation into why clients
rate the alliance as higher, Tryon et al. (2007) suggested that therapists may rate clients
relative to alliances formed with other clients, whereas clients may rate therapists in
comparison to other health professionals who may take a less collaborative, more
paternalistic role, or to friends and family members experienced as (naturally) less
collaborative.
Barriers to treatment participation. A similar pattern of results was found for
barriers to treatment participation. Both client and therapist dyads who made mutual
decisions to end therapy indicated fewer barriers to treatment than did clients and therapist
dyads where the client made a unilateral decision to leave. Contrary to hypotheses, there was
no difference in client-therapist perspective congruence between unilateral and mutual

decision groups. In general, clients rated barriers to treatment participation as higher than did
therapists. This was the first examination, to my knowledge, of Kazdin’s barriers to
treatment participation scale in adult clients. The current pattern of results was different than
Kazdin et al. (1997) in that clients in the present study reported significantly more barriers
than did their therapists, whereas parents of conduct-disordered children in Kazdin et al.’s
study reported significantly fewer barriers than did their therapists. This may be due to
differences in client demographics and presenting problems, or therapist experience given
the trainee therapist sample in the present study. Further research should be conducted to
replicate these results, however, this study indicates that therapists can expect that as clients
experience more barriers, they are more likely to make unilateral decisions to leave therapy.
Limitations. The retrospective assessment of perceived barriers and reasons for
termination raises issues of biased recall, as it was conducted at the end of therapy, after
termination decisions had already been made. However, given that the timing of the post-
therapy assessment was within one month after termination, recall bias is less likely. Due to
logistical constraints, the time lag between end of therapy and completion of the BTPS and
the reasons for termination measure was within one month for unilateral terminators, and
within one week for mutual terminators, potentially adding further measurement biases of an
unknown nature. It is possible that treatment outcome influenced the results: mutually
terminating clients were less symptomatic and higher functioning post-therapy and,
therefore, may have reported fewer barriers as a result of experiencing greater improvement.
As Kazdin and Wassell (2000) discussed, assessing barriers at other therapy points (e.g.,
early in treatment, or on multiple occasions throughout treatment) have their own
methodological and practical liabilities (e.g., clients not having a complete idea of barriers
early in treatment, confounding number of assessment administrations with duration in
treatment and possibly sensitizing clients to the challenges of attending psychotherapy).
Future research should examine other methods of assessing barriers to treatment throughout
the therapy process.
Summary. This was the first study to obtain parallel information from both members
of the client-therapist dyad about specific reasons why the client terminated services, and to
examine how these perspective divergences regarding reasons for termination, early working
alliance, and barriers to treatment participation are related to unilateral termination. When
clients made unilateral decisions to end therapy, therapists were only partially aware of either
the extent of clients’ perceiving success in therapy or with their dissatisfaction. Although
working alliance and barriers to treatment participation were rated as lower in the context of
unilateral termination by both clients and therapists, all clients, in general, rated the early
alliance and barriers to treatment as higher than did their therapists.
Study 3: Psychologists’ Perspectives on Therapy Termination and the Use of Therapy
Engagement Strategies
The main purposes of this study were to examine (a) psychologists’ perspectives of
client termination from psychotherapy and (b) their use of engagement strategies.
Prevalence of unilateral termination. Psychologists reported on the prevalence of
unilateral termination in their own practices. Psychologists reported relatively few clients
who terminated before the third session (M = 13%). Although direct comparisons cannot be
made, consistent evidence from actual client data suggest that psychologists underestimated
the proportion of clients who terminated treatment very early (e.g., on average, 35% - 50% of
clients who complete an intake do not attend the first therapy session: Garfield, 1986;
Hansen et al., 2002; Phillips, 1985; 40% of clients attend fewer than 3 sessions, Pekarik,
1983a). Psychologists reported that a mean of 20% of their clients unilaterally terminated
after the third session, summing to a combined unilateral termination rate of 33%. This value
is consistent with Pekarik & Finney-Owen (1987)’s sample of CMHC therapists who
estimated dropout rates in their overall clinics (32.8%). Pekarik and Finney-Owen also
collected clinic data for a portion of the sample of therapists and found that although
therapists estimated their own dropout rate to be 31.3%, the actual clinic dropout rate was
64.1% (based on 64 consecutive terminations). Pulford et al. (2008) replicated the Pekarik &
Finney-Owen study at an outpatient alcohol and drug treatment service, finding that
therapists estimated that 32% of their clients unilaterally terminated (their proxy dropout
measure was failure to attend a scheduled treatment session), although agency records
indicated the mean rate of this form of client unilateral termination was actually 65%.
Furthermore, the value of 33% reported by psychologists in Study 3 is low when compared
with meta-analytic data showing that 47% of clients prematurely terminate (Wierzbicki &
Pekarik, 1993). Although it is not possible to determine from Study 3 data without
corresponding data on actual unilateral termination, it is likely that psychologists
underestimated unilateral termination in their own practices, perhaps due to spending most of
their time with longer term, mutually terminating clients (Vessey et al., 1994). This is
problematic to the extent that psychologists take action to increase the likelihood appropriate
termination decisions as a function of recognizing that unilateral termination is a significant
problem.
Psychologists’ perspectives of unilateral termination. I examined psychologists’
perspectives of their clients’ reasons for making unilateral decisions to end treatment both
early and later in therapy, as well as mutual decisions. Overall, at least 30% of psychologists
rated each reason for termination as important or very important to clients’ decisions to leave
either before or after the third session, indicating that they perceived numerous reasons as
potentially important to clients’ unilateral decisions to end therapy. Despite attributing
importance to a range of reasons, psychologists viewed lack of motivation as the most
important barrier to treatment engagement, suggesting that psychologists in this study
viewed their clients as playing a decisive role in failure to engage in treatment.
For clients who terminated before versus after the third session, I hypothesized that
psychologists would view circumstantial barriers, clients having to wait too long for services,
and clients having initial negative impressions as more important. This hypothesis was
supported in that psychologists rated these reasons as relatively more important to early
terminators than they did for later unilateral terminators. However, these differences should
be viewed in the context that, across unilateral terminators, psychologists assigned the lowest
importance of any reasons to the influence of wait time and client negative impressions of
clinic and staff in contrast to research showing that wait list length and negative impressions
of office space or staff are important predictors of engagement in therapy (e.g., Festinger et
al., 2002).
In addition to rating these reasons as particularly important for early terminators,
psychologists rated insufficient client motivation, and clients disliking the treatment, as
significantly more important for clients who unilaterally terminated before versus after the
third session. Psychologists rated symptom improvement as significantly more important for
late versus early unilateral terminators, also rating this as the most important reason for
unilateral termination after the third session.

Psychologists’ perspectives of mutual termination. As hypothesized, when their
clients made mutual decisions with them to end, psychologists viewed symptom
improvement as most important, and viewed all other reasons as far less important. As well,
nearly 30% of psychologists rated as important or very important to their mutual decisions to
terminate that clients could not afford to pay. In Canada, where the cost of psychological
services often falls on consumers, this finding is unsurprising. However, only 2% of clients
interviewed in the Canada-wide Canadian Community Health Survey (Cycle 1.2, 2003)
provided this reason (Study 1). Mutual termination was not always viewed as an unqualified
success; approximately 20% of psychologists rated as important or very important that
clients left because they wanted to solve their problems in another way, that clients had
circumstantial barriers, and even that clients lacked motivation or were not ready to change.
Theoretical orientation and reasons for termination. Given preliminary evidence
that CBT therapists may be less vulnerable to the fundamental attribution error than other
therapists (i.e., attributing responsibility for failed therapy to clients; Kendall et al., 1992;
Murdock et al., 2010), I hypothesized that theoretical orientation would influence
psychologists’ perspectives of client reasons for ending therapy. This hypothesis was not
supported; theoretical orientation did not influence psychologists’ perspectives of reasons for
termination. It appears that specific reasons for unilateral termination are viewed similarly
across both CBT and psychologists of different theoretical orientations. Indeed, Kendall and
et al. (1992) found, although rating the importance of this factor lower than did therapists of
other orientations, CBT therapists did rank their clients’ inability to benefit from therapy as
the most important cause of negative outcomes as did other therapists in their study.
Use of engagement strategies. Nearly all psychologists (96.8%) reported that they
often or always focus on building the early working alliance. Using an explicit treatment plan
(74.3% often or always use), and pre-therapy preparation (58.0% often or always use) were
the next most frequently reported strategies. Nearly 40% of psychologists reported the
regular use of client selection and motivational enhancement, and 33% of psychologists
reported regular use of systematic client monitoring. Less than a quarter of psychologists
reported frequent use of time-limited treatment, appointment reminders, or case
management. Older psychologist age was associated with using over half of the engagement
strategies less often. This may reflect differences in graduate training as research
demonstrating the effectiveness of engagement strategies continues to become more
prominent in research and teaching.
I hypothesized that theoretical orientation would influence psychologists’ choice of
engagement strategies. This hypothesis was partially supported; CBT versus psychologists of
other orientations reported more frequent use of systematic client monitoring, and time-
limited treatment, but equivalent use of appointment reminders and case management.
Overall, it appears as though engagement strategies largely transcend theoretical orientation,
and do not reflect theoretical or training differences given their similar use across
psychologists.
Limitations.!Although it was conducted with a relatively large group of
psychologists living in diverse locations in Canada, a limitation of this study is that exact
generalizability is unknown given the lack of data on nationally representative samples of
psychologists. There are larger American and international surveys of therapists across
mental health professions (Cook et al, 2010; Orlinksy, Botermans, & Ronnestad, 2001), but
no representative samples of Canadian psychologists exist for comparison.
As well, nomothetic survey data of psychologists’ perspectives of their clients in
general cannot speak to how psychologists view reasons pertaining to specific clients, or how
they tailor their treatments and use of engagement strategies to specific clients. The method
of measuring reasons for termination and engagement strategies is also limited in that recall
biases may have prevented psychologists from accessing a proportionately accurate portrayal
of both their clients’ reasons for termination and their own use of engagement strategies. As
discussed in reference to Study 1, parallel client or service data would provide an ideal
comparison for psychologists’ perspectives. In terms of measurement of engagement
strategies, it would be ideal for psychologists to monitor their use of strategies in real time
(e.g., track use of engagement strategies on a sessional, daily, or weekly basis). Another
more objective method involves coding for frequency and context of engagement strategies
in videotaped sessions (Cook et al., 2010). Despite these limitations, in order to improve
psychotherapy services, it is essential to be aware of how practicing psychologists’
perspectives generally fit with what is known about client termination and use of engagement
strategies.
Summary. In summary, in this survey of Canadian psychologists regarding their
perspectives on client reasons for termination at different points in therapy and their use of
strategies to engage and retain clients in therapy, psychologists reported that one-third of
their caseload unilaterally terminated. They also assigned differential importance to
termination reasons for this depending on whether termination was before versus after the
third session. Notably, psychologists rated multiple reasons as having at least some
importance to all clients’ decisions to leave therapy. Nevertheless, psychologists viewed lack
of motivation as more important than all other barriers to treatment engagement, and
symptom improvement as the most important reason for unilateral termination after the third
session. Theoretical orientation (CBT versus other) did not influence views of reasons for
termination, but influenced self-reported use of some engagement strategies. Psychologists
reporting a CBT orientation, compared to other therapists, reported more frequent use of
time-limited treatment and systematic client monitoring. Despite these differences, all
psychologists reported at least occasional use of most engagement strategies.
Research Implications
Results from this series of studies on client and therapist perspectives of
psychotherapy termination move us closer to a more complete understanding of termination,
and point to interesting directions for future research. Results from Study 1 provide
population-based evidence that low income increases the likelihood of premature
termination, fitting with meta-analytic data (Wierzbicki & Pekarik, 1993) but not
epidemiological data collected in the United States and Ontario (Edlund et al., 2002). This
discrepancy might be at least partly due to Edlund et al’s different definition of unilateral
termination (individuals who did not select symptom improvement as a reason for
termination, therefore including treatment completers with unilateral terminators). Although
the current study cannot speak to the mechanism of action, the empirical literature provides
some evidence that client-therapist differences in culture, attitudes, and experiences may
contribute (e.g., Ilovsky, 2003). At the present time, the evidence, although incomplete,
supports the utility of client-therapist ethnic matching (Hill et al., 2005), pre-therapy
preparation to increase congruence between client and therapist expectations, and other
strategies to reduce barriers to treatment for these populations such as case management,
time-limited treatment, and very simple additions such as appointment reminders. These
would be fruitful avenues of inquiry with regard to populations at the highest risk of
Study 2 was designed to capture longitudinal, parallel data from clients and therapists.
The first study of its kind in the termination literature, Study 2 provides evidence that
clinicians are more accurate in providing information with regard to specific clients than they
are with regard to their practice as a whole. In the case of mutual termination, there were no
differences in client-therapist ratings of reasons for why termination occurred. Although
differences were systematic and statistically significant with regard to unilateral termination,
they were smaller than what would be suggested by researchers who have surveyed
clinicians based on their practice in general (Pekarik & Finney-Owen, 1987; Vessey et al.,
1994). Garnering parallel data from clients and therapists greatly reduced method variance
that very likely inflated differences in client-therapist perspectives in previous studies
examining this issue (Hunsley et al., 1999; Pekarik & Finney-Owen, 1987; Todd et al.,
2003). Future researchers should continue to include both client and therapist perspectives
and take steps to reduce method variance.
Results from Study 2 also underscore the utility of obtaining parallel data from clients
and therapists because each party offers unique and important information about the
therapeutic process (for example, 22.4% of client-therapist dyads disagreed on whether or
not therapy had terminated prematurely). Results from Study 2 also provide evidence that
clinicians were not fully aware of the barriers clients experience to treatment participation.
This pattern of results was in contrast to Kazdin et al. (1997) in that clients in Study 2
reported significantly more barriers than did their therapists, whereas parents of conduct-
disordered children in Kazdin et al.’s study reported significantly fewer barriers than did
their therapists. This discrepancy may be due to differences in client demographics and
presenting problems, or therapist experience given the trainee therapist sample in Study 2.
Further research should be conducted to replicate these results by taking parallel
measurements of barriers from adult clients and their therapists, ensuring the inclusion of
experienced therapists and a variety of client demographics and presenting problems.
Furthermore, given evidence from Study 2 and from meta-analytic research (e.g., Sharf et al.,
2010) that the working alliance is poorer when measured at the third session for unilateral
terminators, it would be helpful to examine what therapists can do to improve alliances with
clients they find more challenging early in treatment. Safran, Muran, and Eubanks-Cater
(2011) conducted a meta-analysis of studies (k = 8) of the effect of training therapists in
alliance rupture intervention principles on treatment outcome and found that this training
effectively improved outcome (pre-post r = .65). Building on evidence that obtaining regular
feedback from clients about their symptoms (Lambert et al., 2005), the working alliance
(Safran, Muran, Samstag, & Stevens, 2002), and even stage of change (Whipple et al., 2003)
allows clinicians to intervene when clients are off track and improve outcome, it would be
worthwhile to continue this line of research by examining the utility of soliciting regular
feedback about barriers to treatment participation. For example, it would be worthwhile to
examine whether clinicians are more likely to intervene or adjust treatment, and in turn,
whether this improves outcome, if they are more aware of clients’ perceived barriers to
treatment.
It is evident from Study 1 and the termination literature in general that pre-therapy
client characteristics have limited predictive power in terms of alerting therapists to
impending unilateral termination (e.g., Edlund et al., 1992; Wierzbicki & Pekarik, 1993).
Given findings that contextual factors such as barriers to treatment and working alliance are
associated with premature termination, it is important to move toward further monitoring and
investigating the therapeutic process at an even more micro level to identify warning signs of
treatment failure at the level of on-going process. Keijsers, Kampman, and Hoogduiin (2001)
proposed that factors contributing to unilateral termination may be very individualistic and
circumstantial than has been assumed in the research to date. One way to explore these
factors is through qualitative research. For example, Knox et al. (2011) used consensual
qualitative research (a method wherein researchers arrive at consensus via open discussion of
data classification; classification is then reviewed by auditors) to analyze interviews with 12
clients about their termination from psychotherapy. Seven of 12 clients reported unilaterally
terminating. These individuals usually terminated abruptly due to a therapeutic rupture and
perceived harmfulness of therapy. One person reported the rupture as a gradual but
continuous process of invalidation as therapy progressed due to the therapist insisting on
focusing on day-to-day coping skills versus processing painful traumatic experiences.
Although limited in terms of generalizability, small qualitative studies can provide a window
into clients’ experiences of termination and therefore provide avenues for further
investigation.
Greenberg (1986) provided specific methods of investigating change in therapy by
identifying patterns of in-session client and therapist behaviours and connecting them with
client change in functioning. In the context of unilateral termination, researchers might study
what kind of in-therapy interventions, resulting client performances (behavioural responses
to the therapist’s intervention), and in-session outcomes lead to further commitment to
remaining in therapy.
The methodology used in Study 3 of asking psychologists to rate importance of
termination reasons on a continuous scale allowed for the observation that psychologists
consider multiple factors as important to all of their clients’ decisions to terminate. Asking
therapists for their top three reasons only (Pekari, & Finney-Owen, 1987), or any forced
choice methodology, restricts the range of clinician responses and leads to the false
conclusion that clinicians are not aware of multiple factors involved in termination processes
for clients. Future researchers should continue to provide opportunities for respondents to
report on nuances in their perspectives by including multiple sources of information or
gathering supplemental qualitative data.
In Study 3, separating unilateral terminators into early versus later dropouts allowed
for more accurate information about how psychologists in the study viewed client processes.
Indeed, psychologists viewed client termination differently depending on whether it occurred
early (before the third session) or later (after the third session). An important next step is the
operationalization of this division in research on clients in order to better understand unique
factors influencing early versus later termination. In other words, researchers should continue
to divide early versus later unilateral terminators and examine the correlates, experiences,
and reasons for ending therapy separately in these groups.
From Study 3, it is evident that psychologists routinely used some engagement
strategies (i.e., building the early working alliance, in-depth pre-therapy preparation) and
neglected others (i.e., appointment reminders, time-limited treatment). The data suggest that
engagement strategies largely transcended theoretical orientation, and did not reflect
theoretical or training differences given their similar use across psychologists. Sampling
clinicians in real time (or at least closer to the therapy session) would provide more accurate
data regarding their use of engagement strategies. These data could be collected after every
session, daily, or weekly basis. This method of collection would also allow for assessment of
which strategies clinicians use, and which clinicians perceive as effective, with particular
types of client problems. However, self-reported practices might not accurately represent
what clinicians actually do (Hoyt, 2002). For example, clinicians may vary in their
conceptualizations of what building a working alliance looks like due to varying ideas of
how empathy is conveyed, what is helpful, etc. As suggested by Cook et al. (2010), another
more objective but time-consuming method might be to examine random videotaped sessions
of therapy and code for use of engagement strategies. Of course, it is necessary that
clinicians see a pressing need for these strategies and experience them as both practical and
as having clinical utility in order to be willing to implement them. Therefore, it would be
worthwhile to examine clinicians’ views of the utility of these strategies, as well as barriers
to using them.
In addition to greater focus on under-researched strategies (i.e., appointment
reminders), it seems worthwhile for researchers to compare the additional utility of
engagement strategies among different forms of therapy and for various types of client
problems. This would ideally be accomplished using a randomized and controlled design. It
is also worth considering whether the use of multiple strategies is feasible, or outperforms
the concerted use of one or two strategies. For example, it may be that client monitoring is
sufficient unto itself, and further strategies serve to detract focus from core therapeutic
processes such as the therapeutic relationship and theoretically-based techniques.
Another avenue would involve examining the frequency, context, and timing of
strategies used by expert therapists. Some researchers have examined clinicians who
consistently achieve superior outcomes (Miller, Hubble, & Duncan, 2007). Beyond
examining impressionistic or characterological variables such as therapist experience and
perceived trustworthiness, examining therapist behaviours that differentiate therapists who
have the highest rates of mutual termination would be a very fruitful endeavour. Indeed,
Luborsky et al. (1980) suggested that the key factors affecting a client’s decision to leave
may not become evident until the client and therapist begin to interact. For example, Miller
et al. (2006), in a study of the use of client monitoring to improve outcome, found that
therapists who shared their baseline level of success (proportion of client base who
experience clinically significant improvement) with clients experienced a 50% decline in
unilateral termination. Miller et al. speculated that the act of sharing this information served
to elicit a shared engagement with clients. In their work observing sessions of therapists who
achieve superior outcomes, Miller et al. (2007) provided a case description of an expert
therapist. Observers noted her gentle persistence in uncovering clients’ barriers to
participating fully in therapy. This therapist continuously checked in with clients and paid
attention to very slight indicators of ambivalence. Miller et al. described her continuous
attempts to uncover ambivalence and then re-engage the client as differentiating her from
less prodigious therapists. It would appear fruitful for these observations to be examined in
systematic process research, whereby markers for client engagement could be identified.
Finally, Pekarik’s (1985b) definition of the client’s unilateral decision to terminate
best captures the construct of premature termination, as it addresses the problem of
appropriately classifying clients who meet their treatment goals with few therapy sessions as
well as clients who may remain in therapy for a longer period of time, but leave before their
goals have been reached. However, the reality is that some clients who have made unilateral
decisions classify themselves and/or are classified by therapists as mutual terminators
because they discuss their decision with the therapist. This likely occurred in Study 2, where
24 client-therapist dyads (22.4% of the sample) did not agree on the type of termination
decision (12 clients reported unilateral decisions whereas their therapists reported that the
decision was mutual and vice versa). Therefore, the category of mutual termination as
defined this way likely includes unilaterally terminating clients. Furthermore, the category
also includes cases of therapist unilateral termination. Therapists have an ethical obligation
with respect to the way in which termination and referrals are managed. For example, if
termination is initiated by a psychologist, it has to be discussed with the client, therefore
rendering the decision mutual. Indeed, this is the way it is managed in the psychotherapy
termination literature as no studies I found labeled or discussed implications of therapist
unilateral termination. However, many terminations occurred in these studies due to trainee
therapist graduation or practicum rotation. This reality leaves many terminations in which, to
the client, it feels like the termination is entirely determined by the therapist. Indeed, multiple
reasons for mutual decisions to terminate were acknowledged by psychologists in Study 3.
This way of classifying terminations increases the variability in outcomes among mutual
terminators, and does not imply treatment success. Further to obtaining both client and
therapist perspectives on the nature of termination decisions, researchers examining

psychotherapy termination might inquire into the client’s reasoning for labeling the decision
as mutual or unilateral.
Future research might also examine the effects of therapist unilateral terminations on
clients, as well as factors that moderate this impact. For example, factors such as whether an
appropriate and timely referral was made, whether the decision was known in advance (such
as in the case of a maternity leave, training completion, or service mandate) or came
unexpectedly as a result of the therapist’s difficulty working with the client or life
circumstances, may determine the impact on the client. Unexpected therapist unilateral
termination may be very disruptive to client progress in light of evidence that the therapeutic
alliance is crucial to therapy outcome. On the other hand, in addition to using engagement
strategies and trying alternative techniques, appropriately referring clients who do not
progress may be the most ethical decision for the client (eg., Keith-Spiegel & Koocher, 1985;
Kendall et al., 1992).
Clinical Implications
A few main clinical implications emerge from these studies. First, therapists need to be
aware that many clients make unilateral decisions to leave their treatments before their goals
have been reached. Base rates suggest that over half of clients choose to end their treatments
for reasons other than completion of treatment or feeling better. Although it is not possible to
directly compare different samples, and thus the evidence from these studies is indirect,
discrepancies in client reports of premature termination in Study 1 and psychologist reports
in Study 3 fit with previous evidence showing that therapists tend to underestimate unilateral
termination in their own practices, perhaps due to spending most of their time with longer
term, mutually terminating clients (Vessey et al., 1994). Therapists need to recognize the
possibility of memory bias and maintain their awareness of actual versus perceived rates of
unilateral termination. They might accomplish this by setting up a system of monitoring the
proportion of their clients who unilaterally terminate, which would fit easily into existing
systems of monitoring outcomes (e.g., Whipple et al., 2003). Furthermore, there are readily
identifiable risk factors for unilateral termination: non-White ethnicity, low income, and
having a diagnosable mental health disorder. In an effort to target these at-risk groups,
clinicians can educate themselves in culturally appropriate methods, and tailor engagement
strategies to target at-risk groups (e.g., pre-therapy preparation and case management).
Some discrepancies in client and therapist reports merit attention. Many psychologists
in Study 3 cited circumstantial barriers and financial limitations as important reasons why
clients unilaterally terminated, whereas these reasons had exceptionally low prevalence in
the population survey of clients. This discrepant reporting is very likely at least partially due
to method variance, however, discrepant reporting about financial limitations may partially
be accountable to the type of service reported on (psychological versus a range of publicly
funded mental health services) as well. Clients commonly cite circumstantial barriers when
surveyed in the context of clinic studies, however, very few clients cite this reason on a
population level. This low endorsement could be due to the nature of the specific examples
provided in the reason (transportation, schedule, childcare), that former clients are more apt
to provide honest reasons rather than acceptable excuses for termination to an anonymous
interviewer rather than clinic staff or research staff affiliated with the clinic where
termination occurred, or even that, when clients have time to make sense of their termination
decisions, they realize that their dissatisfaction with therapy, or wanting to solve problems in
another way, were more salient factors. Indeed, Hunsley et al. (1999) found that
circumstantial reasons for ending therapy were highly correlated with dislike of therapy.
Clinicians should be mindful of the possibility that clients who report circumstantial barriers
to therapy continuance, including financial limitations, may also be dissatisfied with the
services they are receiving.
Therapists should be cognizant that when treatment ends because of a client’s
unilateral decision, their perspectives on the reasons why therapy ended likely diverge from
their client’s. Specifically, therapists are likely to underestimate the extent of both clients’
dissatisfaction (including clients’ perceptions of therapy going nowhere, making things
worse, lack of confidence in the therapist, and lack of congruence in ideas about what would
be helpful) and goal attainment. Undoubtedly, clients do not always share either their
positive or negative experiences (Hill et al., 1993), however, therapists may be unaware of
their clients’ feelings for other reasons. Some research has shown that therapist failure to
recognize shortcomings is associated with decreased competence. For example, Brosan,
Reynolds, and Moore (2008) found that less competent cognitive therapists (as rated by
expert observers) rated themselves as significantly more competent than experts did when
rating a tape of one of their sessions from the middle of therapy. In contrast, more competent
therapists showed greater convergence in self and expert ratings. Najavits and Strupp (1993)
examined therapist effectiveness as measured by outcome data. More effective therapists,
according to clinic outcome data, had greater regrets about their performance, rating
themselves as making more mistakes during the session than less effective therapists. These
results suggest that more effective therapists may be more realistic and less afraid to critique
their own performance or contributions to failed therapy. These findings have direct
implications for training: therapists should be indoctrinated in the idea that reflecting upon
one’s performance and constructively criticizing one’s clinical decisions indicate the
presence, and not the absence of, competence or confidence. The literature on experts – not
just expert therapists – is useful to illustrate what learning therapists might be taught: experts
continually seek out areas of weakness, practice in their leading growth edge, consistently
look for feedback, and follow up to determine the effectiveness of their new behaviours
(Miller et al., 2007). Although further research is required to fully delineate factors that
differentiate therapists who achieve superior versus average outcomes, Miller et al. (2006)
reported results of a case investigation in which they found that novice or non-expert
therapists were more likely to attribute client failure to engage to denial, resistance, or lack of
motivation, whereas expert therapists were more likely to reflect on their interventions and
think of new alternatives to responding to a particular client, and then further anticipate how
the client will respond and plan therapeutic strategies for each response. This places the
therapist in a position to try new ways of engaging clients, and expanding their skills in terms
of what works for specific clients.
Miller et al. (2006) advocate knowing one’s baseline level of success so that therapists
may be aware of the extent of improvement as a result of deliberate practice. Perhaps it
might be useful for trainees to track client outcomes for this purpose in addition to receiving
supervisor feedback. In terms of additional training implications, it would seem that the
most facilitative supervision environment would be one in which trainees are reinforced for
developing an awareness of both their strengths and weaknesses, and sharing moments of
perceived poor performance or great challenge. Further, trainees should be reinforced for
deliberately soliciting negative feedback from their clients. Presumably, trainees feel more
comfortable raising issues of competence and client dissatisfaction in a supervisory context

in which open discussion of these problems is normative. It behooves clinician training
programs to evaluate whether deliberately fostering these competencies in trainees is
effective for improving client outcomes and reducing unilateral termination.
Study 2 elucidated one prospective cue for unilateral termination – a poorer working
alliance at the third session. Furthermore, unilaterally terminating clients as a group were
characteristic of lower therapist-rated functioning, higher self-rated symptomatology, and
more barriers to participation in treatment. This lack of congruence in perspectives speaks to
the importance of pre-therapy preparation to establish a shared vision of treatment, tracking
client progress and soliciting client feedback on the working alliance, barriers to treatment,
and client perceptions of how therapy is progressing. Only then are therapists able to take
steps to bring therapy back on track by collaboratively problem-solving with the client to
repair alliance ruptures, shift the focus of therapy, or help clients to overcome circumstantial
barriers. There is good evidence that soliciting and modifying therapy based on client
feedback has the potential to get therapy back on track (e.g., Lambert et al., 2005; Miller et
al., 2006; Whipple et al., 2003).
Study 3 data from psychologists indicate that insufficient motivation/lack of
readiness for change was the primary reason that psychologists in this study believed clients
unilaterally terminated treatment before the third session. Lack of readiness for change is
undoubtedly a reason for unilateral termination for some clients (e.g., Prochaska, Rossi, &
Wilcox, 1991), regardless of whether or not therapists accurately detect the frequency of
such clients (i.e., therapists’ recall may be biased because of being able to recall such clients
with particular ease due to the frustration they experienced with these unmotivated clients).
Fortunately, client motivation for change is dynamic in nature, and a growing body of
literature shows that therapists can influence it with the methods they use in therapy (e.g.,
Arkowitz, Westra, Miller, & Rollnick, 2007). Therapists should be aware that they might
view unilaterally terminating clients as unmotivated when the client is experiencing
problems with the process of therapy additional reasons (e.g., dissatisfaction, lack of fit,
feeling as though therapy is going nowhere). It is important for therapists to be aware of
multiple reasons for unilateral termination, and the potential fallacy of attributing
responsibility to the client for failed therapy (e.g., Kendall et al., 1992).
The empirical literature provides ample evidence that it is often beneficial (and never
detrimental) for therapists to deliberately employ strategies to engage and retain clients in
therapy (Barrett et al., 2008; Ogrodniczuk et al., 2005). The results from Study 3 provide
evidence that engagement strategies largely transcend theoretical orientation, and reflect
neither theoretical nor training differences given their similar use across psychologists. It
seems worthwhile for therapists of any theoretical orientation to consider how some of these
strategies fit with their approach to therapy and their clients. Notably, psychologists in Study
3 reported a low frequency of use of case management and appointment reminders. Clients
with mental health problems often experience concurrent difficulties with practical life
problems. Sometimes these practical issues become barriers to proceeding with therapy.
Indeed, results from Study 2 indicate that therapists underestimated the extent of clients’
perceived barriers to treatment participation. Therapists should actively solicit clients’
barriers in an effort to increase awareness of them, as results from Manfred-Gilham et al.
(2002) showed that therapists who were aware of client barriers used more engagement
strategies to keep the client in treatment. Additionally, it would be worthwhile for therapists
to consider appropriate use of case management in an effort to assist clients in overcoming or

managing these barriers. Given their ubiquity in medical and health-related professions, the
use of appointment reminders would seem a simple strategy to implement, particularly with
clients who have forgotten at least one appointment.
In Study 3, psychologists assigned the lowest importance of any termination reasons to
the influence of wait time and client negative impressions of clinic environment and staff in
contrast to research showing that wait list length and negative impressions of office space or
staff are important predictors of engagement in therapy (e.g., Festinger et al., 2002;
Stasiewicz & Stalker, 1999). Clinicians should be mindful that these factors can play a
significant role early in the therapy process. Fortunately, there are ways of dealing with these
risk factors such as temporarily closing down the wait list and providing a referral so that
they client may access services in a timely manner, paying attention to office décor, and
training reception staff in sensitive etiquette.
Conclusion
In conclusion, despite five decades of empirical attempts to discriminate unilateral
versus mutual terminators, few replicable results have been found further to non-White
ethnicity and socioeconomic status. Knowledge of these general demographic risk factors
provides little help in understanding what therapists can change to improve retention for all
clients. Moving away from static demographic variables and closer to the therapeutic
experience, examining reasons for termination provides a way to learn about a multitude of
factors that contribute to unilateral termination. Furthermore, examining reasons from the
perspective of both clients and therapists is necessary for a complete understanding of
termination. In this series of three studies, I used population data to examine the prevalence
of client reasons and their correlates, parallel and longitudinal clinic data from clients and
their therapists to provide an accurate assessment of the congruence of their perspectives,
and data from psychologists to provide the first information about how experienced
therapists view client termination at different points in therapy, and the strategies they use to
engage and retain their clients. In the context of the empirical literature, this research
provides evidence that researchers may best focus their efforts on helping therapists to bridge
key gaps in perspective between themselves and their clients. With further refinement of
applied research methods, we can proceed to more accurately and systematically identifying
clients at risk and intervening to reduce the number of clients who end therapy before
meeting their objectives.

References
Acosta, F.X. (1980). Self-described reasons for premature termination of psychotherapy by
Mexican American, Black American, and Anglo-American patients. Psychological
Reports, 47, 435-443.
Alcázar Olán, R.J., Deffenbacher, J.L., Hernández Guzmán, L., Sharma, B., & de la
Chaussée Acuña, M.E. (2010). The impact of perceived therapist characteristics on
patients decision to return or not return for more sessions. International Journal of
Psychology and Psychological Therapy, 10, 415-426.
disorders (4th ed., text rev.). Washington, DC: Author.
Arkowitz, H. & Westra, H.A. (2009). Introduction to the special issue on motivational
interviewing and psychotherapy. Journal of Clinical Psychology: In Session, 65(11),
1149-1155.
Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (Eds.; 2008). Motivational
Interviewing in the Treatment of Psychological Problems New York: Guilford Press.
Armbruster, P., & Kazdin, A.E. (1994). Attrition in child psychotherapy. Advances in
Clinical Child Psychology, 16, 81-108.
Bachelor, A., & Salame, R. (2000). Participants’ perceptions of dimensions of the
therapeutic alliance over the course of therapy. Journal of Psychotherapy Practice and
Research, 9, 39-53.

Baekland, F. & Lundwall, L. (1975). Dropping out of treatment: A critical review.
Psychological Bulletin, 82, 738-783.
Baker, A., Kochan, N., Dixon, J. & Heather, N. (1994). Controlled evaluation of a brief
intervention for HIV prevention among injecting drugs users not in treatment. AIDS
Care, 6, 559-570.
Barber, J.P., Morse, J.Q., Krakauer, I.D., Chit-Tams, J., & Crits-Christoph, K. (1997).
Change in obsessive-compulsive and avoidant personality disorders following time-
limited supportive-expressive therapy. Psychotherapy: Theory, Research, Practice,
Training, 34, 133-143.
Barkham, M., Connell, J., Stiles, W.B., Miles, J.N.V., Margison, F., Evans, C., & Mellor-
Clark, J. (2006). Dose-effect relations and responsive regulation of treatment duration:
The good enough level. Journal of Consulting and Clinical Psychology, 74, 160-167.
Barkham, M., Rees, A., Stiles, W.B., Hardy, G.E., & Shapiro, D. (2002). Dose-effect
relations for the psychotherapy of mild depression: A quasi-experimental comparison
of effects of 2, 8, and 16 sessions. Psychotherapy Research, 12, 263-274.
Barkham, M., Shapiro, D.A., Hardy, G.E., & Rees, A. (1999). Psychotherapy in two-plus-
one sessions: Outcomes of a randomized controlled trial of cognitive-behavioral and
psychodynamic-interpersonal therapy for subsyndromal depression. Journal of
Consulting and Clinical Psychology, 67, 201-211.
Barrett, M.S., Chua, W.J., Crits-Cristoph, P., Gibbons, M.B., & Thompson, D. (2008). Early
withdrawal from mental health treatment: Implications for psychotherapy practice.
Psychotherapy Theory, Research, Practice, Training, 45, 247-267.

Barrett, M.S., Chua, W., & Thompson, D. (2007). Predicting dropout among women
receiving community-based mental health treatment. Paper presented at the annual
meeting of the Society for Psychotherapy Research, Madison, WI.
Baumann, B., Hilsenroth, M., Ackerman, S., Baity, M., Smith, C., Smith, S., Blagys, M.,
Price, J., Heindselman, T., Mount, M., & Holdwick, D. (2001). The Capacity for
Dynamic Process Scale (CDPS): An examination of reliability, validity, and relation to
therapeutic alliance. Psychotherapy Research, 11, 275-294.
Beck, N.C., Lamberti, J., Gamache, M., Lake, E.A., Fraps, C.L., McReynolds, W.T., et al.
(1987). Situational factors and behavioral self-prediction in the identification of clients
at high risk to drop out of psychotherapy. Journal of Clinical Psychology, 43, 511-520.
Beckham, E.E. (1992). Predicting patient dropout in psychotherapy. Psychotherapy: Theory,
Research, Practice, Training, 29, 177-182.
Bernard, H.S., & Drob, S.L. (1989). Premature termination: A clinical study. Group, 13, 11-
22.
Berrigan, L.P., & Garfield, S.L.(1981). Relationship of missed psychotherapy appointments
to premature termination and social class. British Journal of Clinical Psychology, 20,
239-242.
Best, M. (2003). Premature termination from adult psychotherapy: Can therapy-specific and
contextual factors help predict who will drop out? (Doctoral dissertation, University of
Ottawa, 2003). Retrieved from ProQuest Digital Dissertations. (AAT NQ89989).
Blagys, M.D., & Hilsenroth, M.J. (2002). Distinctive activities of cognitive-behavioral
therapy: A review of the comparative psychotherapy process literature. Clinical
Psychology Review, 22, 671-706.

Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research, and Practice, 16, 252-260.
Brosan, L., Reynolds, S., & Moore, R.G. (2008). Self-evaluation of cognitive therapy
performance: Do therapists known how competent they are? Behavioural and
Cognitive Psychotherapy, 36, 581-587.
Busseri, M.A., & Tyler, J.D. (2003). Interchangeability of the Working Alliance Inventory
and Working Alliance Inventory, Short Form. Psychological Assessment, 15, 193-197.
Callahan, J.L., Aubuchon-Endsley, N., Borja, S.E., & Swift, J.K. (2009). Pretreatment
expectancies and premature termination in a training clinic environment. Training and
Education in Professional Psychology, 3, 11-119.
in a training clinic. Psychological Services, 3, 129-136.
Canadian Institutes for Health Information (2006) Retrieved February 15, 2010, from
http://secure.cihi.ca/cihiweb/products/Psychologists.pdf
Canadian Psychological Association (2009). Annual Report. Retrieved February 15, 2010,
http://www.cpa.ca/aboutcpa/annualreports/
Carroll, K.M., Libby, B., Sheehan, J., & Hyland, N. (2001). Motivational interviewing to
enhance treatment initiation in substance abusers: An effectiveness study. American
Journal on Addictions, 10, 335-339.
Cartwright, D. (1955). Success in psychotherapy as a function of certain actuarial variables.
Journal of Consulting Psychology, 19, 357-360.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that
work. New York: Oxford University Press.

Castonguay, L.G., Goldfried, M.R., Wiser, S., Raue, P.J., & Hayes, A.M. (1996). Predicting
the effect of cognitive therapy for depression: A study of unique and common factors.
Journal of Consulting and Clinical Psychology, 64, 497-504.
Castonguay, L.G., Schut, A.J., Aikins, D., Constantino, M.J., Laurenceau, J.P., Bologh, L., &
Burns, D.D. (2004). Integrative cognitive therapy: A preliminary investigation. Journal
of Psychotherapy Integration, 14, 4-20.
Chaimowitz, G. (2004). Psychotherapy in psychiatry. Ottawa, ON: Canadian Psychiatric
Association.
Chiesa, M., Wright, M., & Neeld, R. (2003). A description of an audit cycle of early
dropouts from an inpatient psychotherapy unit. Psychoanalytic Psychotherapy, 17,
138-149.
Chisolm, S.M., Crowther, J.H., & Ben-Porath, Y.S. (1997). Selected MMPI-2 scales’ ability
to predict premature termination and outcome from psychotherapy. Journal of
Personality Assessment, 69, 127-144.
Chua, W.J., & Barrett, M. (2007, October). The influence of physical environment on
engagement in psychotherapy. Paper presented at the annual meeting of the North
American Society for Psychotherapy Research, New York.
Colby, S.M., Monti, P.M., Barnett, N.P., Rohsenow, D.J., Weissman, K., Spirito, A., et al.
(1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A
preliminary study. Journal of Consulting and Clinical Psychology, 66, 574-578.
Constantino, M.J., Arnkoff, D.B., Glass, C.R., Ametrano, R.M., & Smith, J.Z. (2011).
Expectations. Journal of Clinical Psychology, 67, 184-192.

Cook, J.M., Biyanova, T., Elhai, J., Schnurr, P.P., & Coyne, J.C. (2010). What do
psychotherapists really do in practice? An internet study of over 2,000 practitioners.
Psychotherapy Theory, Research, Practice, Training, 47, 260-267.
Corning, A.F., Malofeeva, E.V., & Bucchianeri, M.M., (2007). Predicting termination type
from client-therapist agreement on the severity of the presenting problem.
Craig, T., & Huffine, C. (1976). Correlates of patient attendance in an innercity mental
health clinic. American Journal of Psychiatry, 133, 61-64.
Crits-Christoph, P., Connolly Gibbons, M.B., Crits-Cristoph, K., Narducci, J., Schamberger,
M., & Gallop, R. (2006). Can therapists be trained to improve their alliances? A
preliminary study of alliance-fostering psychotherapy. Psychotherapy Research, 16,
268-281.
Crits-Cristoph, P., & Mintz, J. (1991). Implications of therapist effects for the design and
analysis of comparative studies of psychotherapies. Journal of Consulting and Clinical
Derogatis, L.R, Lipman, R.S., & Covi, L. (1973). The SCL-90: An outpatient rating scale –
Preliminary report. Psychopharmacology Bulletin, 9, 13-38.
Dyck, R.J., Joyce, A.S., & Azim, H.F.A. (1984). Treatment noncompliance as a function of
therapist attributes and social support. Canadian Journal of Psychiatry, 29, 212-216.
Eaton, T.T., Abeles, N., & Gutfreund, M.J. (1988). Therapeutic alliance and outcome:
Impact of treatment length and pretreatment symptomatology. Psychotherapy, 25, 536-
542.
Edlund, M. J., Wang, P. S., Berglund, P. A., Katz, S. J., Lin, E., & Kessler., R. C. (2002).
Dropping out of mental health treatment: Patterns and predictors among
epidemiological survey respondents in the United States and Ontario. American
Elkin, I., Yamaguchi, J.L., Arnkoff, D.B., Glass, C.R., Sotsky, S.M., & Krupnick, J.L.
(1999). Patient-treatment fit and early engagement in therapy. Psychotherapy
Research, 9, 437-451.
Endicott, J., Spitzer, R.L., Fleiss, J.L., & Cohen, J. (1976). The Global Assessment Scale: A
procedure for measuring overall severity of psychiatric disturbance. Archives of
General Psychiatry, 33, 766-771.
Epperson, D.L., Bushway, D.J., & Warman, R.E. (1983). Client self-terminations after one
counseling session: effects of problem recognition, counselor gender, and counselor
experience. Journal of Counseling Psychology, 30, 307-315.
Feld, R., Woodside, D.B., Kaplan, A.S., Olmset, M.P., & Carter, J.C. (2001). Pretreatment
motivational enhancement therapy for eating disorders: A pilot study. International
Journal of Eating Disorders, 29, 393-400.
Festinger, D.S., Lamb, R.J., Marlow, D.B., & Kirby, K.C.(2002). From telephone to office:
Intake attendance as a function of appointment delay. Addictive Behaviors, 27, 131-
137.
Fitzpatrick, M.R., Iwakabe, S., & Stalikas, A. (2005). Perspective divergence in the working
alliance. Psychotherapy Research, 15, 69-79.

Flaskerud, J.H., & Liu, P.Y. (1991). Effects of an Asian client-therapist language, ethnicity
and gender match on utilization and outcome of therapy. Community Mental Health
Journal, 27, 31-42.
Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H., & Stone, A.R. (1957). Why patients
leave psychotherapy. Archives of Neurology, 77, 283.
Frayn, D.H. (1992). Assessment factors associated with premature psychotherapy
termination. American Journal of Psychotherapy, 46, 250-261.
client satisfaction. Dissertation Abstracts International: Section B: The Science and
Garb, H. N., & Boyle, P. A. (2003). Understanding why some clinicians use pseudoscientific
methods: Findings from research on clinical judgment. In S. O. Lilienfeld, S. J. Lynn,
& J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology (pp. 17-38).
New York: Guilford.
Garfield, S.D., (1986). Research on client variables in psychotherapy. In S.L. Garfield &
A.E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp/213-
256). New York: Wiley.
Garfield, S.L., (1994). Research on client variables in psychotherapy. In A.E. Bergin & S.L.
Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 190-228). New
York: Wiley.
Gravel, R., & Béland, Y. (2005). The Canadian Community Health Survey: Mental Health
and Well-Being. Canadian Journal of Psychiatry, 50, 573-579.

Greenberg, L.S. (1986). Change process research. Journal of Consulting and Clinical
Greenspan, M., & Kulish, N.M. (1985). Factors in premature termination in long-term
psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 22, 75-82.
Grimes, W.R., & Murock, N.L. (1989). Social influence revisited: Effects of counselor
influence on outcome variables. Psychotherapy: Theory, Research, Practice, Training,
26, 269-474.
Gunzburger, D.W., Henggeler, S.W., & Watson, S.M. (1985). Factors related to premature
termination of counseling relationships. Journal of College Student Personnel, 26, 456-
460.
Hannan, C., Lambert, M., Harmon, C., Nielson, S., Smart, D., Shimokawa, K., & Sutton,
S.W. (2005). A lab test and algorithms for identifying clients at risk for treatment
failure. Journal of Clinical Psychology, 61, 155-163.
Hansen, N.B., Lambert, M.J., & Forman, E.M. (2002). The psychotherapy dose-response
effect and its implications for treatment delivery services. Clinical Psychology: Science
and Practice, 9, 329-343.
Hatchett, G.T., Han, K., & Cooker, P.G. (2002). Predicting premature termination from
counseling using the Butcher Treatment Planning Inventory Assessment. Counseling
Psychologist, 9, 156-163.
Hatchett, G.T., & Park, H.L. (2003). Comparison of four operational definitions of premature
termination. Psychotherapy: Theory, Research, Practice, Training, 40, 226-231.

Hawley, K.M., & Weisz, J.R. (2003). Child, parent, and therapist (dis)agreement on target
problems in outpatient therapy: The therapist’s dilemma and its implications. Journal
of Consulting and Clinical Psychology, 71, 62-70.
Hersoug, A.G., Hoglend, P., Monsen, J.T., & Havik, O.E. (2001). Quality of working
alliance in psychotherapy: Therapist variables and patient/therapist similarity as
predictors. Journal of Psychotherapy Practice and Research, 10, 205-216.
Hill, C.E., Thompson, B.J., Cogar, M.C., & Denman, C. (1993). Beneath the surface of long-
term therapy: Therapist and client report of their own and each other’s covert
processes. Journal of Counseling Psychology, 40, 28-287.
Hilsenroth, M.J., Peters, E.J., & Ackerman, S.J. (2004). The development of therapeutic
alliance during psychological assessment: Patient and therapist perspectives across
treatment. Journal of Personality Assessment, 83, 332-344.
Horenstein, D. & Houston, B.K. (1976). The expectation-reality discrepancy and premature
termination from psychotherapy. Journal of Clinical Psychology, 32, 373-378.
Horvath, A.O., Del Re., A.C., Flückiger, C., & Symonds, D. (2011). Alliance in individual
psychotherapy. Psychotherapy, 48, 9 – 16.
Horvath, A.O., & Greenberg, L.S. (1986). The development of the Working Alliance
Inventory. In L.S. Greenberg and W.M. Pinsof (Eds.), The psychotherapeutic process:
A research handbook (pp. 529-556). New York: Guilford.
Horvath, A.O., & Greenberg, L.S. (1989). Development and validation of the Working
Alliance Inventory. Journal of Counseling Psychology, 36, 223-233.
Horvath, A.O., & Symonds, B.D. (1991). Relation between working alliance and outcome in
psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139-149.

Howard, K.I,, Kopta, S.M., Krause, M.S., & Orlinsky, D.E. (1986). The dose-effect
relationship in psychotherapy. American Psychologist, 41, 159-164.
Hoyt, W.T. (2002). Bias in participant ratings of psychotherapy process: An initial
generalizability study. Journal of Counseling Psychology, 49, 35-46.
Humfress, H., Igel, V., Lamont, A., Tanner, M., Morgan, J., & Schmidt, U. (2002). The
effect of a brief motivational intervention on community psychiatric patients’ attitudes
to their care, motivation to change, compliance and outcome: A case control study.
Journal of Mental Health, 11, 155-166.
388.
Hunsley, J., & Lee, C.M. (2007). Research-informed benchmarks for psychological
treatments: Efficacy studies, effectiveness studies, and beyond. Professional
Hunt, C., & Andrews, G. (1992). Drop-out rate as a performance indicator in psychotherapy.
Acta Psychiatrica Scandinavia, 85, 275-278.
Hynan, D.J. (1990). Client reasons and experiences in treatment that influence termination of
psychotherapy. Journal of Clinical Psychology, 46, 891-895.
Iacoviello, B.M., McCarthy, K.S., Barrett, M.S., Rynn, M., Gallop,, R., & Barber, J.P.
(2007). Treatment preferences affect the therapy alliance: Implications for randomized
controlled trials. Journal of Consulting and Clinical Psychology, 75, 194-198.

Joe, G.W., Simpson, D.D., Greener, J.M., & Rowan-Szal, G.A. (1999). Integrative modeling
of client engagement and outcomes during the first 6 months of methadone treatment.
Addictive Behaviors, 24, 649-659.
Johansson, H., & Eklund, M. (2005). Helping alliance and early dropout from psychiatric
out-patient care: The influence of patient factors. Social Psychiatry and Psychiatric
Epidemiology, 41, 140-147.
Joyce, A.S., Ogrodniczuk, J.S., Piper, W.E., & McCallum, M. (2003). The alliance as a
mediator of expectancy effects in short-term individual therapy. Journal of Consulting
Kazdin, A.E., (1996). Dropping out of child psychotherapy: Issues for research and
implications for practice. Clinical Child Psychology and Psychiatry, 1, 133 – 156.
Kazdin, A.E., Holland, L., Crowley, M., & Breton, S. (1997). Barriers to treatment
participation scale: Evaluation and validation in the context of child outpatient
treatment. Journal of Child Psychology and Psychiatry, 38, 1051-1062.
Kazdin, A. E., Mazurik, J. L., & Siegel, T. C. (1994). Treatment outcome among children
33, 549-557.
Kazdin, A.E., & Wassell, G. (1998). Predictors of barriers to treatment and therapeutic
change in outpatient therapy for antisocial children and their families. Mental Health
Services Research, 2, 27-40.
Keijsers, G.P.J., Kampman, M., & Hoogduin, C.A.L. (2001). Dropout prediction in cognitive
behaviour therapy for panic disorder. Behavior Therapy, 32, 739-749.

Keijsers, G.P.J., Schaap, C.P.D.R., Hoogduin, C.A.L., Hoogsteyns, B., & de Kemp, E.C.M.
(1999). Preliminary results of a new instrument to assess patient motivation for
treatment in cognitive-behaviour therapy. Behaviour and Cognitive Psychotherapy, 27,
165-179.
Keith-Spiegel, P., & Koocher, G. P. (1985). Ethics in psychology. Hillsdale, NJ: Erlbaum.
16, 269-281.
Kenny, D.A., Kashy, D.A., & Bolger, N. (1998). Data analysis in social psychology. In D.
Gilbert, S.T. Fiske, & G. Lindzey (Eds.), Handbook of Social Psychology (4th ed. Vol
1, pp.233-265). New York: McGraw Hill.
Kessler, R. C., & Ustun, T. B. (2004). The World Mental Health (WMH) Survey Initiative
Version of the World Health Organization (WHO) Composite International Diagnostic
Interview (CIDI). International Journal of Methods in Psychiatric Research, 13, 93-
121.
Kim, D.M., Wampold, B.E., & Bolt, D.M. (2006). Therapist effects in psychotherapy: A
random-effects modeling of the National Institute of Mental Health Treatment of
Depression Collaborative Research Program data. Psychotherapy Research, 16(2),
161-172.
Knaup, C., Koesters, M., Schoefer, D., Becker, T., & Puschner, B. (2009). Effect of feedback
of treatment outcome in specialist mental healthcare: Meta-analysis. The British

Kokotovic, A.M., & Tracey, T.J. (1987). Premature termination at a university counseling
center. Journal of Counseling Psychology,34, 80-82.
Kolb, D.L., Beutler, L.E., Davis, C.S., Crago, M., & Shanfield, S.B, (1985). Patient and
therapy process variables relating to dropout and change in psychotherapy.
Psychotherapy: Theory, Practice, & Research, 22, 702-710.
Kushner, M.G., & Sher, K.J. (1989). Fear of psychological treatment and its relation to
mental health service avoidance. Professional Psychology: Research and Practice, 20,
251-257.
Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative
and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of
psychotherapy integration (pp. 94-129). New York: Basic Books.
Lambert, M.J., Harmon, C., Slade, K., Whipple, J.L., & Hawkins, E.J. (2005). Providing
feedback to psychotherapists on their patients’ progress: Clinical results and practice
suggestions Journal of Clinical Psychology, 61,165-74.
Lambert, M.J., & Ogles, B.M. (2004). The efficacy and effectiveness of psychotherapy. In
M.J., Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior
change (5th ed)., pp. 139-193. New York: Wiley.
Lambert, M.J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-
79.
Lambert, M.J., Whipple, J.L., Hawkins, E.J., Vermeersch, D.A., Nielsen, S.L., & Smart,
D.W. (2003). Is it time for clinicians to routinely track patient outcome? A meta-
analysis. Clinical Psychology: Science and Practice, 10, 288-301.

Latour, D., & Cappeliez, P. (1994). Pretherapy training for group cognitive therapy with
depressed older adults. Canadian Journal of Aging, 13, 221-235.
Lebow, J. (1982). Consumer satisfaction with mental health treatment. Psycshological
Bulletin, 91, 244-259.
Link, B. G., & Dohrenwend, B. P. (1980). Formulation of hypotheses about the true
relevance of demoralization in the United States. In B.P. Dohrenwend, B.S.
Dohrenwend, M.S. Gould, B. Link, R. Neugebauer, et al. (Eds.), Mental illness in the
United States: Epidemiological estimates (pp. 114-132). New York: Praeger
Publishers.
Luborsky, L., Mintz, J., Auerbach, A., Crits-Cristoph, P., Bachrach, H., Todd, T., Johnson,
M., Cohen, M., & O’Brien, C.P. (1980). Predicting the outcome of psychotherapy:
Findings of the Penn Psychotherapy Project. Archives of General Psychiatry, 37, 471-
481.
Maguire, M.C. (1999). Treating the dyad as the unit of analysis: A primer on three analytic
approaches. Journal of Marriage and the Family, 61, 213-223.
Manfred-Gilham, J.J., Sales, E., & Koeske, G. (2002). Therapist and case manager
perceptions of client barriers to treatment participation and use of engagement
strategies. Community Mental Health Journal, 38, 213-221.
Manthei, R.J. (1996). A follow-up study of clients who fail to begin counseling or terminate
after one session. International Journal for the Advancement of Counselling, 18, 115-
128.
Martin, D.J., Garske, J.P., & Davis, M.K. (2000). Relation of the therapeutic alliance with
outcome and other variables: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 68, 438-450.
Mash, E. J., & Hunsley, J. (1993). Assessment considerations in the identification of failing
psychotherapy: Bringing the negatives out of the darkroom. Psychological Assessment,
5, 292-301.
McNeill, B.W., May, R.J., Lee, V.E. (1987). Perceptions of counselor source characteristics
by premature and successful terminators. Journal of Counseling Psychology, 34, 86-89.
Meyer, B., Pilkonis, P.A., Krupnick, J.L., Egan, M.K., Simmens, S.J., & Sotsky, S.M.
(2002). Treatment expectancies, patient alliance, and outcome: Further analyses from
the National Institute of Mental Health Treatment of Depression Collaborative
Research Program. Journal of Consulting and Clinical Psychology, 70, 1051-1055.
Miller, S.D., Barry, L., Duncan, G.S., Brown, J., Sorrell, R., & Chalk, M.B. (2006). Using
formal client feedback to improve retention and outcome: Making ongoing, real-time
assessment feasible. Journal of Brief Therapy, 5, 5-22.
Miller, S.D., Hubble, M. & Duncan, G.S. (2007). Supershrinks. Who are they? What can we
learn from them? Psychotherapy Networker. November/December, 27-56.
Miranda, J., Azocar, F., Organista, K.C., Dwyer, E., & Arean, P. (2003). Treatment of
depression among impoverished primary care patients from ethnic minority groups.
Psychiatric Services, 54, 219-225.
Mohl, P.C., Martinez, D., Ticknor, C., Huang, M., & Cordell, L. (1991). Early dropouts from
psychotherapy. Journal of Nervous and Mental Disease, 179, 478-481.

Mojtabai, R., & Olfson, M. (2008). National trends in psychotherapy by office-based
psychiatrists. Archives of General Psychiatry, 65, 962 - 970.
relationship to dropout, outcome, and satisfaction. Psychotherapy, 37, 117-123.
Navajits, L.M., & Strupp, H.H. (1994). Differences in the effectiveness of psychodynamic
therapists: A process-outcome study. Psychotherapy, 31, 114-123.
Newman, M.G., Kenardy, J., Herman, S., & Taylor, C.B. (1997). Comparison of cognitive-
behavioral treatment of panic disorder with computer-assisted brief cognitive-
behavioral treatment. Journal of Consulting and Clinical Psychology, 65, 178-183.
Nguyen, T.D., Attkisson, C.C., & Stegner, B.L. (1983). Assessment of patient satisfaction:
Development and refinement of a service evaluation questionnaire. Evaluation and
Program Planning, 6, 299-314.
Norcross, J.C., & Goldfried, M.R. (Eds). (2005). Handbook of Psychotherapy Integration.
Oxford University Press: New York.
Norcross,J.C., Karpiak, C.P., & Santoro, S.O. (2005). Clinical psychologists across the
years: The division of clinical psychology from 1960 to 2003. Journal of Clinical
Psychology, 61, 1467-1483.
Oei, T.P.S., & Kazmierczak, T. (1997). Factors associated with dropout in a group cognitive
behaviour therapy for mood disorders. Behaviour Therapy and Research, 11, 1025-
1030.
57-70.
Orlinsky, D.E., Botermans, J.F., & Ronnestad, M.H. (2001). Towards an empirically
grounded model of psychotherapy training : Four thousand therapists rate influences on
their development. Australian Psychology, 36, 139-148.
Pekarik, G. (1983a). Follow-up adjustment of outpatient dropouts. American Journal of
Orthopsychiatry, 53, 501-511.
Pekarik, G. (1983b). Improvement in clients who have given different reasons for dropping
Pekarik, G. (1985a). Coping with dropouts. Professional Psychology: Research and
Practice, 16, 114-123.
Pekarik, G. (1985b). The effects of employing different termination classification criteria in
dropout research. Psychotherapy, 22, 86-91.
Pekarik, G. (1986). The use of treatment termination status and treatment duration patterns as
an indicator of clinical improvement. Evaluation and Program Planning, 9, 25-30.
Pekarik, G. (1991). Relationship of expected and actual treatment duration for adult and
child clients. Journal of Clinical Child Psychology, 20, 121-125.
Pekarik, G., & Wierzbicki, M. (1986). The relationship between clients’ expected and actual
treatment duration. Psychotherapy, 23, 532-534.

Persons, J., Burns, D. D., & Perloff, J. M. (1988). Predictors of dropout and outcome in
cognitive therapy for depression in a private practice setting. Cognitive Therapy and
Research, 12, 557-575.
Persons, J. B., & Mikami, A.Y. (2002). Strategies for handling treatment failure successfully.
Phillips, E. L. (1985). Psychotherapy revisited: New frontiers in research and practice.
Phillips, E. L. (1987). The ubiquitous decay curve: Service decline similarities in
psychotherapy, medicine, and addiction. Professional Psychology, Research, and
Practice, 18, 650-652.
Prilleltensky, I. (2003). Poverty and powder. In: Carr, S.C., Sloan, T.S. (Eds). Poverty and
psychology: From global perspective to local practice. New York: Kluwer
Academic/Plenum Press, pp. 19-44.
Prinz, R.J., & Miller, G.E. (1994). Family-based treatment for childhood antisocial
behaviour: Experimental influences on dropout and engagement. Journal of Consulting
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more
integrative model of change. Psychotherapy: Theory, Research, & Practice, 19, 276-
288.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people
change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.

Prochaska, J.O., & Norcross, J.C. (198). Contemporary psychotherapists: A national survey
of characteristics, practices, orientations, and attitudes. Psychotherapy: Theory,
Research and Practice, 20, 161-173.
Rainer, J.P., & Campbell, L.F. (2001). Premature termination in psychotherapy:
identification and intervention. Journal of Psychotherapy Independent Practice, 2, 19-
41.
Raudenbush, S. W. Bryk, A. S. (2002). Hierarchical linear models: Applications and data
analysis methods (2nd ed.). Newbury Park, CA: Sage.
Regan, A.M., & Hill, C.E. (1992). Investigation of what clients and counselors do not say in
brief therapy. Journal of Counseling Psychology, 39, 168-174.
Reis, B.F., & Brown, L.G. (2006). Preventing therapy dropout in the real world: The clinical
utility of videotape preparation and client estimate of treatment duration. Professional
Richmond, R. (1992). Discriminating variables among psychotherapy dropouts from a
psychological training clinic. Professional Psychology: Research and Practice, 23,
123-130.
Robiner, W.N. (2006). The mental health professions: Workforce supply and demand issues,
and challenges. Clinical Psychology Review, 26, 600-625.
Rodolfa, E.R., Rapaport, R., & Lee, V.E. (1983). Variables related to premature
terminations in a university counseling service. Journal of Counseling Psychology, 30,
87-90.
Rogers, C.P. (1951). Client-centered therapy. Boston: Houghton Mifflin.
Rosen, C.S., Drescher, K.D., Moos, R.D., Finney, J.W., Murphy, R.T., & Gusman, F. (2000).
Six and ten item indices of psychological distress based on the Symptom Checklist-90.
Assessment, 7, 103-111.
Rubak, S., Sanbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing:
A systematic review and meta-analysis. British Journal of General Practice, 55, 305-
312.
Rubenstein, E.A., & Lorr, M.A. (1956). Comparison of terminators and remainders in
outpatient psychotherapy. Journal of Clinical Psychology, 12, 345.
Rumstein-McKean, O. (2005). Seeking and engaging in psychotherapy:Investigating the
comparative value of two models (Doctoral dissertation, University of Ottawa, 2005).
Retrieved from ProQuest Digital Dissertations. (AAT NQ89989).
Saatsi, S., Hardy, G.E., & Cahill, J. (2007). Predictors of outcome and completion status in
cognitive therapy for depression. Psychotherapy Reseasrch, 17, 185-195.

Safran, J.D., Muran, J.C., Samstag, L.W., & Stevens, C. (2001). Repairing alliance ruptures.
Salta, L., & Buick, W.P. (1989). Impact of organizational change on the intake, referral, and
treatment of outpatients at a community mental health center. Journal of Mental Health
Administration, 16, 71-79.
Saltzman, C., Luetgert, M.J., Roth, C.H., Creaser, J., & Howard, L. (1976). Formation of a
therapeutic relationship: Experiences during the initial phase of psychotherapy as
predictors of treatment duration and outcome. Journal of Consulting and Clinical
Saporito, J.M., Barrett, M.S., McCarthy, K.S., Iacoviello, B., & Barber, J.P. (2003, June).
Predicting failure to attend intake appointment. Paper presented at the annual meeting
of the Society for Psychotherapy Research, Weimar, Germany.
Sayer, A.G., & Klute, M. M. (2005). Analyzing couples and families: Multilevel methods. In
V.L. Bengston, A.C. Acock, K.R. Allen, P. Dilworth-Anderson, & D.M. Klein (Eds).
Sourcebook of family theory and research. (pp. 289-313). Thousand Oaks, CA: Sage.
Scamardo, M., Bobele, M., & Biever, J.L. (2004). A new perspective on client dropouts.
Journal of Systemic Therapies, 23, 27-38.
Shapiro, D.A., Barkham, M., Stiles, W.B., Hardy, G.E., Rees, A., Reynolds, S. & Startup, M.
(2003). Time is of the essence: A selective review of the fall and rise of brief therapy
research. Psychology and Psychotherapy: Theory, Research, and Practice, 76, 211-
235.
Sharf, J., Primavera, L.H., & Diener, M.J. (2010). Dropout and the therapeutic alliance: A
meta-analysis of adult individual psychotherapy. Psychotherapy Theory, Research,
Practice, Training, 47, 637-645.
Siqueland, L., Crits-Christoph, P., Barber, J.P., Butler, S.F., Thase, M., Najavits, L., &
Onken, L.S. (2000). The role of therapist characteristics in training effects in cognitive,
supportive expressive and drug counseling therapies for cocaine dependence. Journal
of Psychotherapy, Practice, and Research, 9, 123-130.
Sledge, W.H., Moras, K., Hartley, D., & Levine, M. (1990). Effect of time-limited
psychotherapy on patient dropout rates. American Journal of Psychiatry, 147, 1341-
1347.
Smith, K.J., Subich, L.M., & Kalodner, C. (1995). The transtheoretical model’s stages and
processes of change and their relation to premature termination. Journal of Counseling
Sotsky, S.M., Glass, D.E., Shea, M.T., Pilkonis, P.A., Collins, J.F., Elkin, I., et al. (1991).
Patient predictors of response to psychotherapy and pharmacotherapy: Findings in the
NIMH Treatment of Depression Collaborative Research Program. American Journal of
Psychiatry, 148, 997-1008.
Sparks, W.A., Daniels, J.A., & Johnson, E. (2003). Relationship of referral source, race, and
wait time on preintake attrition. Professional Psychology: Research and Practice, 34,
514-518.
Stasiewicz, P.R., & Stalker, R. (1999). A comparison of three “interventions” on
pretreatment dropout rates in an outpatient substance abuse clinic. Addictive Behaviors,
24, 579-582.
Statistics Canada (2001a). Income statistics for Ottawa-Hull. Retrieved July 26, 2003, from
Statistics Canada 2001 Community Profiles Online:
http://www12.statcan.ca/english/profil01/Details/details1inc2.cfm?SEARCH=BEGINS
NAME=Ottawa%20%2D%20Hull%CMA=&SEARCH=BEGINS&DataType=1&Typ
eNameE=Census%20Metropolitan%20Area&ID=805
Statistics Canada (2001b). Population statistics for Ottawa-Hull. Retrieved July 26, 2003,
from Statistics Canada 2001 Community Profiles Online:
http://www12.statcan.ca/enlish/profil01/Details/details1pop2.cfm?SEARCH=BEGINS
NAME=Ottawa%20%2D%20Hull&CMA=&SEARCH=BEGINS&DataType=1&Type
NameE=Census%20Metropolitan%20Area&ID=805
Statistics Canada (2003). Canadian community health survey mental health and well-being.
Retrieved from: http://www.statcan.ca/english/freepub/82-617-XIE/index.htm.
Stein, L.I., & Santos, A.B. (1998). Assertive community treatment of persons with severe
mental illness. New York: Norton.
Stewart, R.E., & Chambless, D.L. (2008). Treatment failures in private practice: How do
psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181.
Sue, S., Fujino, D.C., Hu, L., Takeuchi, D.T., & Zane, N.W.S. (1991). Community mental
health services for ethnic minority groups: A test of the cultural responsiveness
hypothesis. Journal of Consulting and Clinical Psychology, 59, 533-540.

Smith, T.E., Koenigsberg, H.W., Yeomans, F.E., Clarkin, J.F., & Selzer, M.A. (1995).
Predictors of dropout in psychodynamic psychotherapy. Journal of Psychotherapy
Practice and Research, 4, 205-213.
Swift, J.K., & Callahan, J.L. (2008). A delay discounting measure of great expectations and
the effectiveness of psychotherapy. Professional Psychology: Research and Practice,
39, 581-588.
46, 328-335.
Tabachnick, B.G., & Fidell, L.S. (2007). Experimental designs using ANOVA. Belmont, CA:
Thompson, Brooks, and Cole.
Thormählen, B., Weinryb, R.M., Norén, K., Vinnars, B., & Bagedåhl-Strindlund, M. (2003).
Patient factors predicting dropout from supportive-expressive psychotherapy for
patients with personality disorders. Psychotherapy Research, 13, 493-509.
Tracey, T.J. (1986). Interactional correlates of premature termination. Journal of Consulting
Tracey, T.J. (1988). Relationship of responsibility attribution congruence to psychotherapy
outcome. Journal of Social and Clinical Psychology, 7, 131-146.
Tracey, T.J., & Kokotovic, A.M. (1989). Factor structure of the working alliance inventory.
Psychological Assessment, 1, 207-210.

Tryon, G., Blackwell, S., & Hammel, E. (2007). A meta-analytic examination of client-
therapist perspectives of the working alliance. Psychotherapy Research, 17, 629-642.
Tryon, G.S., Winograd, G. (2002). Goal consensus and collaboration. In J.C. Norcross
Psychotherapy Relationships That Work, pp.109-128. Oxford University Press: New
York, New York.
Tryon, G.S., & Winograd, G. (2011). Goal consensus and collaboration. Psychotherapy, 48,
50-57.
Turner, A.J., & Vernon, J.C. (1976). Prompts to increase attendance in a community mental
health center. Journal of Applied Behavior Analysis, 9, 141-145.
Tutin, J.A., (1987). A multivariate analysis of dropout status by length of stay in a rural
community mental health center. Community Mental Health Journal, 23, 40-52.
Vail, A. (1978). Factors influencing lower-class Black patients remaining in treatment.
Journal of Consulting and Clinical Psychology, 46, 341.
Walitzer, K.S., Dermen, K.H., & Connors, G.J. (1999). Strategies for preparing clients for
treatment. Behavior Modification, 23, 239-252.
Wang, J. (2007). Mental health treatment dropout and its correlates in a general population
sample. Medical Care, 45, 224-229.
Watkins, C.E. (1997). Reflections on contemporary psychotherapy practice, research, and
training. Journal of Contemporary Psychotherapy, 27, 5-22.

Weerasekera, P., Linder, B., Greenberg, L., Watson, J. (2001). The working alliance in
client-centered and process-experiential therapy of depression. Psychotherapy
Research, 11, 221-233.
Whipple, J.L., Lambert, M.J., Vermeersch, D.A., Smart, D.W., Nielsen, S.L., & Hawkins,
E.J. (2003). Improving the effects of psychotherapy: The use of early identification of
treatment failure and problem-solving strategies in routine practice. Journal of
Counseling Psychology, 50, 59-68.
Zwick, R., & Attkisson, C.C. (1985). Effectiveness of a client pretherapy orientation
videotape. Journal of Counseling Psychology, 32, 514-524.

Appendix A: Study 2 Client Demographic Information
ID Number
1. Gender M F 2. Age
3. Who referred you to the Centre? Self Other
4. Are you:
1. Single 4. Separated
2. Living with your partner 5. Divorced
3. Married 6. Widowed
5. Do you have any children? Y N If yes, how many?

Living with you? Y N
6. Have you ever been in therapy before? Y N If yes, when?
7. Are you currently seeking psychological services elsewhere? Y N
8. What is your highest level of education?
1. 1.Some elementary school 6. Graduated college

2. Finished elementary school 7. Some university
3. Some high school 8. Graduated university
4. Graduated high school 9. Graduate school
5. Some college 10. Professional school
9. What is your current employment status?
1.Unemployed 4. Employed part time

2.Student 5. Retired
3.Employed full time 6. Homemaker
10. What is your current annual income?
1. 0 - $5,000 4. $15,001 - $20,000 7. $30,001 - $35,000

2. $5,001 - $10,000 5. $20,001 - $25,000 8. $35,001 - $40,000
3. $10,001 - $15, 000 6. $25,001 - $30,000 9. $40,001 or more
ID Number
11. What is your ethnic background?
1. White (e.g., Europe, S. America) 7. Native/Aboriginal People of North America

2. Black 8. South Asian (e.g., India, Uganda, Pakistan)
3. Korean 9. South East Asian (e.g., Vietnamese, Thai)
4. Filipino 10. Middle Eastern/North African (e.g.,
5. Japanese Armenia, Syria, Morocco)
6. Chinese 11. Other
Appendix B: Study 2 Symptom Checklist - 10 (SCL-10)
ID Number
Here is a list of problems and complaints that people sometimes have. Consider each item carefully,
and indicate which response best describes HOW MUCH DISCOMFORT THAT PROBLEM HAS
CAUSED YOU DURING THE PAST WEEK INCLUDING TODAY. Before we start, please write
down the rating scale because it will make it easier for you to answer items.
0 1 2 3 4
Not at all A little bit Moderately Quite a bit Extremely
1 How much were you distressed by feeling lonely? 0 1 2 3 4
2. How much were you distressed by feeling no interest in things? 0 1 2 3 4
3. How much were you distressed by feeling afraid in open spaces

or on the streets? 0 1 2 3 4
4. How much were you distressed by feeling weak in part of your

body? 0 1 2 3 4
5. How much were you distressed by feeling blue? 0 1 2 3 4
6. How much were you distressed by heavy feelings in your arms

or legs? 0 1 2 3 4
7. How much were you distressed by feeling afraid to go out of your

house alone? 0 1 2 3 4
8. How much were you distressed by feeling tense or keyed up? 0 1 2 3 4
9. How much were you distressed by feelings of worthlessness? 0 1 2 3 4
10. How much were you distressed by feeling lonely even when you
are with people? 0 1 2 3 4
Appendix C: Study 2 Working Alliance InventoryBClient Form
ID Number
Below is a list of statements about your relationship with your therapist. Consider each item carefully
and indicate your level of agreement for each of the following items.
Does not Corresponds Corresponds

Correspond at all Moderately Exactly
1 2 3 4 5 6 7
1. My therapist and I agree about the things I will need to do in therapy to help
improve my situation. 1 2 3 4 5 6 7
2. What I am doing in therapy gives me new ways of looking at my problem. 1 2 3 4 5 6 7
3. I believe my therapist likes me. 1 2 3 4 5 6 7
4. My therapist does not understand what I am trying to accomplish in therapy. 1 2 3 4 5 6 7
5. I am confident in my therapist=s ability to help me. 1 2 3 4 5 6 7
6. My therapist and I are working towards mutually agreed upon goals. 1 2 3 4 5 6 7
7. I feel that my therapist appreciates me. 1 2 3 4 5 6 7
8. We agree on what is important for me to work on. 1 2 3 4 5 6 7
9. My therapist and I trust one another. 1 2 3 4 5 6 7
10. My therapist and I have different ideas on what my problems are. 1 2 3 4 5 6 7
11. We have established a good understanding of the kind of changes that

would be good for me. 1 2 3 4 5 6 7
12. I believe the way we are working with my problem is correct. 1 2 3 4 5 6 7

Appendix D: Study 2 Working Alliance InventoryBClinician Form
ID Number
Below is a list of statements about your relationship with your client. Consider each item carefully and
indicate your level of agreement for each of the following items.
Does not Corresponds Corresponds

Correspond at all Moderately Exactly
1 2 3 4 5 6 7
1. My client and I agree about the things he/she will need to do in therapy to help
improve his/her situation. 1 2 3 4 5 6 7
2. What my client is doing in therapy gives him/her new ways of looking at

his/her problem. 1 2 3 4 5 6 7
3. I believe my client likes me. 1 2 3 4 5 6 7
4. My client does not understand what I am trying to accomplish in therapy. 1 2 3 4 5 6 7
5. I am confident in my client=s ability to help him/herself. 1 2 3 4 5 6 7
6. My client and I are working towards mutually agreed upon goals. 1 2 3 4 5 6 7
7. I feel that my client appreciates me. 1 2 3 4 5 6 7
8. We agree on what is important for my client to work on. 1 2 3 4 5 6 7
9. My client and I trust one another. 1 2 3 4 5 6 7
10. My client and I have different ideas on what his/her problems are. 1 2 3 4 5 6 7
11. We have established a good understanding of the kind of changes that

would be good for him/her. 1 2 3 4 5 6 7
12. I believe the way we are working with my client=s problem is correct. 1 2 3 4 5 6 7
Appendix E: Study 2 Global Assessment of Functioning (GAF) Scale
Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-
illness. Do not include impairment in functioning due to physical (or environmental) limitations.
Code (Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.)
100 Superior functioning in a wide range of activities, life=s problems never seem to get out
! of hand, is sought out by others because of his or her many positive qualities.
91 No symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all
! areas, interested and involved in a wide range of activities, socially effective, generally satisfied with
life, no more than everyday problems or concerns (e.g., an occasional argument with family
81 members).
80 If symptoms are present, they are transient and expectable reactions to psychosocial
! stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in
71 social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
70 Some mild symptoms (e.g, depressed mood and mild insomnia) OR some difficulty in
! social, occupational, or school functioning (e.g., occasional truancy, or theft within the household),
61 but generally functioning pretty well, has some meaningful interpersonal relationships.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic
! attacks) OR moderate difficulties in social, occupational, or school functioning (e.g., few
51 friends, conflicts with peers or co-workers).
50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any
! serious impairment in social occupational, or school functioning (e.g., no friends, unable to keep a
41 job).
40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or
! irrelevant) OR major impairment in several areas, such as work or school, family relations, judgement,
thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to
31 work; child frequently beats up younger children, is defiant at home, and is failing at school).
30 Behaviour is considerably influenced by delusions or hallucinations OR serious impairment in

! communication or judgement (e.g., sometimes incoherent, acts grossly inappropriately, suicidal
preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home,
21 or friends).
20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death;
! frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene
11 (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability
! to maintain minimal personal hygiene OR serious suicidal act with clear expectation
1 of death.
0 Inadequate information.
Appendix F: Study 2 Barriers to Treatment Participation Scale - Client
ID Number
There can be a number of things that get in the way of someone participating fully in their treatment.
Below is a list of possible barriers or obstacles you may have encountered while in therapy. Please
indicate how much of a problem for you each potential barrier was.
HOW OFTEN DID THIS STRESSOR OR OBSTACLE CREATE A PROBLEM FOR YOU
WHILE YOU WERE IN TREATMENT?
___________________________________________________________________________________
1 2 3 4 5
Never Once in a while Sometimes Often
Very Often
1. Transportation (getting a ride driving, taking a bus) to the clinic for a session 1 2 3 4 5
2. Scheduling of appointment times for treatment 1 2 3 4 5
3. Treatment was in conflict with another of my activities (classes, job, friends) 1 2 3 4 5
4. During the course of treatment I experienced a lot of stress in my life 1 2 3 4 5
5. I was sick on the day when treatment was scheduled 1 2 3 4 5
6. Crises at home made it hard for me to get to a session. 1 2 3 4 5
7. Treatment added another stressor to my life. 1 2 3 4 5
8. There was bad weather and this made coming to treatment a problem 1 2 3 4 5
9. I did not have time for the assigned work 1 2 3 4 5
10. There was always someone sick in my home 1 2 3 4 5
11. Getting a baby-sitter so I could come to the sessions 1 2 3 4 5
12. Finding a place to park at the clinic 1 2 3 4 5
13. I had a disagreement with my husband/wife, boyfriend/girlfriend, partner
about whether I should come to treatment at all 1 2 3 4 5
14. I was too tired after work to come to a session 1 2 3 4 5
15. My job got in the way of coming to a session 1 2 3 4 5
16. Treatment took time away from spending time with my children 1 2 3 4 5
HOW OFTEN DID THESE ISSUES CREATE A PROBLEM FOR YOU WHILE YOU WERE IN
TREATMENT?
17. Treatment lasted too long (too many weeks) 1 2 3 4 5

18. I felt that treatment cost too much 1 2 3 4 5
19. I was billed for the wrong amount 1 2 3 4 5
20. Information in the session and any handouts seemed confusing 1 2 3 4 5
21. I had trouble understanding the treatment I received 1 2 3 4 5
22. I felt this treatment was more work than expected 1 2 3 4 5
23. The atmosphere at the clinic makes it uncomfortable for appointments 1 2 3 4 5
_____________________________________________________________________________________
1 2 3 4 5
Never Once in a while Sometimes Often Very Often
24. I did not feel that I had enough to say about what goes on in treatment 1 2 3 4 5
25. The assigned work for me to do as part of this treatment was much too difficult 1 2 3 4 5
HOW OFTEN DID YOU FEEL THIS WAY ABOUT YOUR TREATMENT?
26. Treatment did not seem necessary 1 2 3 4 5

27. Treatment was not what I expected 1 2 3 4 5
28. I lost interest in coming to sessions 1 2 3 4 5
29. I felt treatment did not seem as important as the sessions continued 1 2 3 4 5
30. I feel treatment did not focus on my life and problems 1 2 3 4 5
31. I now have new or different problems 1 2 3 4 5
32. My problems seem to have improved, therefore, treatment no longer seems
necessary 1 2 3 4 5
33. Treatment did not seem to be working 1 2 3 4 5
HOW OFTEN DID YOU FEEL THIS WAY ABOUT YOUR THERAPIST?
34. I did not like the therapist 1 2 3 4 5

35. I felt I had to give too much personal information to the therapist 1 2 3 4 5
36. The therapist did not seem confident that treatment would work for me 1 2 3 4 5
37. The therapist did not seem confident in my ability to make changes 1 2 3 4 5
38. I do not feel the therapist supported me or my efforts 1 2 3 4 5
Appendix G: Study 2 Termination Questions for the Client
ID Number
1. In essence, was the decision to terminate therapy (check one only)
a) a unilateral, explicit decision on your part to end therapy?_____
b) based on your own decision not to attend sessions or to schedule subsequent appointments?
____
c) a mutual agreement between you and your therapist that treatment goals had been met? ____
d) due to a decision that you would receive services elsewhere?____

Appendix H: Study 2 Reasons for Termination – Client
People choose to end therapy for a number of reasons. Below is a list of reasons that may have
influenced your decision to end treatment. Please indicate how important you believe each reason
was in your decision to end therapy.
____________________________________________________________________________________
1 2 3 4
Not at all important Somewhat Important Important Very Important
1. You accomplished what you wanted to do in therapy 1 2 3 4
2. You could no longer fit time for therapy into your schedule 1 2 3 4
3. You just lost interest in therapy 1 2 3 4
4. You no longer had money or insurance coverage to pay 1 2 3 4
5. You felt therapy was going nowhere so ended therapy 1 2 3 4
6. You felt therapy was making things worse so stopped 1 2 3 4
7. You weren’t confident in your therapist’s ability to help 1 2 3 4
8. You were uncomfortable talking about personal matters 1 2 3 4
9. Therapy didn’t fit with your ideas about what would be helpful 1 2 3 4
10. You decided to go elsewhere for services 1 2 3 4

Appendix I: Study 2 Barriers to Treatment Participation Scale - Therapist
ID Number ________
There can be a number of things that get in the way of someone participating fully in their
treatment. Below is a list of possible barriers or obstacles your client may have encountered while in
therapy. Please indicate how much of a problem you think each potential barrier was for your client.
HOW OFTEN DID THIS STRESSOR OR OBSTACLE CREATE A PROBLEM FOR YOUR
CLIENT WHILE HE/SHE WAS IN TREATMENT?
____________________________________________________________________________________
1 2 3 4 5
1. Transportation (getting a ride driving, taking a bus) to the clinic for a session 1 2 3 4 5
2. Scheduling of appointment times for treatment 1 2 3 4 5
3. Treatment was in conflict with another of their activities (classes, job, friends) 1 2 3 4 5
4. During the course of treatment they experienced a lot of stress in their life 1 2 3 4 5
5. They were sick on the day when treatment was scheduled 1 2 3 4 5
6. Crises at home made it hard for them to get to a session. 1 2 3 4 5
7. Treatment added another stressor to their life. 1 2 3 4 5
8. There was bad weather and this made coming to treatment a problem 1 2 3 4 5
9. They did not have time for the assigned work 1 2 3 4 5
10. There was always someone sick in their home 1 2 3 4 5
11. Getting a baby-sitter so they could come to the sessions 1 2 3 4 5
12. Finding a place to park at the clinic 1 2 3 4 5
13. They had a disagreement with their husband/wife, boyfriend/girlfriend, partner
about whether they should come to treatment at all 1 2 3 4 5
14. They were too tired after work to come to a session 1 2 3 4 5
15. Their job got in the way of coming to a session 1 2 3 4 5
16. Treatment took time away from spending time with their children 1 2 3 4 5
HOW OFTEN DID THESE ISSUES CREATE A PROBLEM FOR YOUR CLIENT WHILE
HE/SHE WAS IN TREATMENT?
17. Treatment lasted too long (too many weeks) 1 2 3 4 5

18. They felt that treatment cost too much 1 2 3 4 5
19. They were billed for the wrong amount 1 2 3 4 5
20. Information in the session and any handouts seemed confusing 1 2 3 4 5
21. They had trouble understanding the treatment they received 1 2 3 4 5
22. They felt this treatment was more work than expected 1 2 3 4 5
23. The atmosphere at the clinic made it uncomfortable for appointments 1 2 3 4 5
_____________________________________________________________________________________
1 2 3 4 5
24. They did not feel that they had enough to say about what went on in treatment 1 2 3 4 5
25. The assigned work for them to do as part of this treatment was much too difficult 1 2 3 4 5
HOW OFTEN DO YOU THINK YOUR CLIENT FELT THIS WAY ABOUT THEIR
TREATMENT?
26. Treatment did not seem necessary 1 2 3 4 5

27. Treatment was not what they expected 1 2 3 4 5
28. They lost interest in coming to sessions 1 2 3 4 5
29. They felt treatment did not seem as important as the sessions continued 1 2 3 4 5
30. They felt treatment did not focus on their life and problems 1 2 3 4 5
31. They now have new or different problems 1 2 3 4 5
32. Their problems seem to have improved, therefore, treatment no longer seems
necessary 1 2 3 4 5
33. Treatment did not seem to be working 1 2 3 4 5
HOW OFTEN DO YOU THINK YOUR CLIENT FELT THIS WAY ABOUT THEIR
THERAPIST?
34. They did not like the therapist 1 2 3 4 5

35. They felt they had to give too much personal information to the therapist 1 2 3 4 5
36. The therapist did not seem confident that treatment would work for them 1 2 3 4 5
37. The therapist did not seem confident in their ability to make changes 1 2 3 4 5
38. They do not feel the therapist supported them or their efforts 1 2 3 4 5
Appendix J: Study 2 Termination Questions for the Clinician
ID Number
1. In essence, was the decision to terminate therapy (check one only)
a) a unilateral, explicit decision on the part of the client to end therapy? ____
b) based on the failure of the client to attend sessions to schedule subsequent

appointments? ____
c) a mutual agreement between you and the client that treatment goals had been met?
____
d) due only to reaching the limit of 20 treatment sessions? ____
e) due to a decision for the client to receive services elsewhere?____

Appendix K: Study 2 Reasons for Termination – Therapist
People choose to end therapy for a number of reasons. Below is a list of reasons that may
have influenced your client’s decision to end treatment. Please indicate how important
you believe each reason was in your client’s decision to end therapy.
__________________________________________________________________________
1 2 3 4
Not at all important Somewhat Important Important Very Important
1. My client accomplished what he/she wanted to do in therapy 1 2 3 4
2. My client could no longer fit time for therapy into your schedule 1 2 3 4
3. My client just lost interest in therapy 1 2 3 4
4. My client no longer had money or insurance coverage to pay 1 2 3 4
5. My client felt therapy was going nowhere so ended therapy 1 2 3 4
6. My client felt therapy was making things worse so stopped 1 2 3 4
7. My client wasn’t confident in my ability to help 1 2 3 4
8. My client was uncomfortable talking about personal matters with me 1 2 3 4
9. Therapy didn’t fit with their ideas about what would be helpful 1 2 3 4
10. My client decided to go elsewhere for services 1 2 3 4

Appendix L: Study 3 Email List Recruitment Script
As part of my doctoral dissertation research, along with Dr. John Hunsley, C. Psych., I
am conducting a 10-minute online survey of psychologists and psychological associates
regarding their experiences and views on adult clients' termination from psychotherapy.
If you are interested in participating in this survey, please go to the following link for
further information:
http://www.surveymonkey.com/s/endingtherapy
Thank you in advance,
Robin Westmacott, M.A.

PhD Candidate, University of Ottawa
Dr. John Hunsley, C.Psych. and Robin Westmacott, MA, of the University of Ottawa are
conducting a brief online survey of psychologists and psychological associates regarding
their experiences and views on adult clients' termination from psychotherapy. If you are
interested in participating in this survey, please go to the following link for further
information:
http://www.surveymonkey.com/s/endingtherapy
Appendix M: Study 3 CPA Recruit Research Participants Portal Script
Title: Clients’ reasons for ending psychotherapy.
Abstract: For my dissertation research, I am seeking psychologists or psychological

associates in supervised or autonomous practice who provide individual psychotherapy to
adults to complete a short questionnaire about issues around client termination. Results of
this study will provide useful information regarding client termination at different points
in therapy. Furthermore, the results will provide information about the use of strategies
for retaining clients that are used in regular practice. I invite you to take 15 minutes to
complete this online survey examining issues around client termination. Participation in
research is voluntary. If you choose to participate in this study you may withdraw at any
time. No identifying information will be collected. Researchers: Robin Westmacott, M.A.
& John Hunsley, Ph.D. (C. Psych). Please contact Robin Westmacott if you have any
questions. A summary of findings will be provided when the study is complete. This
research has been approved by the University of Ottawa Research Ethics Board.
Researcher: Robin Westmacott, M.A.
Study Population: Psychologists or psychological associates who provide individual

psychotherapy to adults.
Participant Obligation: Completion of questionnaires will take approximately 15 minutes.
Location: Online-Ottawa
Study Runs: September 1, 2010 to December 1, 2010
URL: http://www.surveymonkey.com/endingtherapy
Appendix N: Study 3 Informed Consent
Title of the study: Clients’ Reasons for Ending Psychotherapy
Researchers: Robin Westmacott, M.A., School of Psychology

John Hunsley, Ph.D. (C. Psych), School of Psychology
Invitation to Participate: If you are a psychologist or psychological associate in

supervised or autonomous practice, you are invited to complete a short questionnaire
about issues around client termination.
Purpose of the Study: The purpose of the study is to shed light on psychologists’
perspectives of client termination at different points in therapy. Furthermore, results will
provide information about the use of strategies for retaining clients that are used in
regular practice.
Participation: Your participation will consist of completing an online survey that will
take approximately 10 minutes.
Risks: Your participation in this study will not incur any risk.
Benefits: Your participation in this study will contribute to the advancement of

knowledge around issues related to client termination from therapy. If requested, a
summary of findings will be provided when the study is complete.
Confidentiality and anonymity: The information you will share will remain strictly
confidential. The contents will be used only for purposes outlined above, and your
confidentiality will be protected as you will not be asked for identifying information.
Anonymity is assured as you will not be asked for identifying information. IP addresses
will not be collected.
Conservation of data: The data collected will be kept in a secure manner (password
protected survey, computer, and locked laboratory).
Voluntary Participation: You are under no obligation to participate and if you choose to
participate, you can withdraw from the study at any time and/or refuse to answer any
questions, without suffering any negative consequences. If you choose to withdraw, all
data gathered until the time of withdrawal will be entered as incomplete. If you wish to
withdraw all of your responses, you may do so by contacting us.
Acceptance (check one):
_____ I accept to participate in the above research study conducted by Robin

Westmacott, M.A. of the University of Ottawa, whose research is under the supervision
of John Hunsley, Ph.D. (C. Psych).
_____ I refuse to participate in the study.
If you have any questions about the study, you may contact the researcher or her
supervisor. Please print a copy of this consent form for your records and for future
reference.
If you have any questions regarding the ethical conduct of this study, you may contact the
Protocol Officer for Ethics in Research, University of Ottawa
Appendix O: Study 3 Survey
SURVEY
We are conducting a study about how psychologists/psychological associates view their clients’ reasons for ending therapy. If you are
a psychologist/psychological associate in supervised or autonomous practice and you provide individual psychotherapy to adults, we
invite you to take 15 minutes to complete this survey examining issues around client termination.
Clients in your practice:
We are interested in three distinct groups of clients who end therapy; 1) clients who initiate services but fail to engage in
psychotherapy, 2) clients who engage in services and make a unilateral decision to end, and 3) clients who engage in services and
make a mutual decision with their therapist to end therapy.
1. In your own practice, what proportion of clients would you estimate end treatment (responses should add to 100):
a. ______ After the intake session but before session 3 (i.e., the proportion of clients who fail to engage in
psychotherapy)
b. ______ After session 3, but making a unilateral decision to terminate
c. ______ After engaging in therapy, but making a mutual decision with you to terminate
2. In your own practice: For clients who attended an intake session but who left therapy before session 3, how important, from
your perspective, are the following reasons to the decision to terminate?
Not important Somewhat important Very important

at all
a. Clients reached their goals or symptoms improved 0 1 2 3 4

b. Clients wanted to solve their problems in another way 0 1 2 3 4
c. Clients were not ready to change, or had insufficient
motivation 0 1 2 3 4
d. Clients were unable to benefit from therapy 0 1 2 3 4
e. Clients believed that therapy was not helping 0 1 2 3 4
f. Clients disliked the treatment 0 1 2 3 4
g. Clients had to wait too long for services 0 1 2 3 4
h. Clients had negative impressions of my office
or staff 0 1 2 3 4
i. Clients could not afford to pay 0 1 2 3 4
j. Clients had circumstantial barriers such as
transportation, childcare, or schedule issues 0 1 2 3 4
3. In your own practice: For clients who engage in psychotherapy (attend an intake and at least 3 sessions), and make unilateral
decisions to end therapy, how important are the following reasons to their decision to terminate (from your perspective)?

at all


or staff 0 1 2 3 4
4. In your own practice: for clients who engage in psychotherapy and make mutual decisions with you to terminate, how
important are the following reasons to their decision to terminate (from your perspective)?

at all

or staff 0 1 2 3 4
In addition to information on general patterns in your practice, we would also appreciate having information on some specific clients
who recently terminated therapy. As you are reporting on specific clients in the following questions, your ratings may be either
similar to or different from the ratings you just gave on general patterns in your practice
Thank you for responding to questions about reasons clients end therapy in your practice. We would appreciate knowing a
few other things about you and your practice.
1. Please rate the extent to which you use the following strategies to increase engagement and reduce unilateral termination in
general in your practice?
Never use Sometimes use Always use
a. Client selection 0 1 2 3 4
(either do not accept certain clients for therapy,
or stop providing services if services are not
working)
b. in-depth pre-therapy preparation 0 1 2 3 4

(i.e., prior to commencing therapy,
teaching the client about the rationale
for therapy, role expectations, how treatment
progresses, common misconceptions about
psychotherapy, and possible difficulties one
may experience during therapy)
c. Be explicit about negotiating an agreed upon 0 1 2 3 4

treatment plan
d. Set a time limit on the number of therapy

sessions 0 1 2 3 4
e. Motivational enhancement (i.e., prior to

beginning 0 1 2 3 4
therapy, initiate procedures that increase
the client’s willingness to enter into
and remain engaged
in treatment)
f. Explicitly foster a strong working alliance

early in treatment 0 1 2 3 4
g. Case management (i.e., provide practical support

to the client regarding difficult life circumstances
that may preclude participation in therapy,
including directly assisting the client with
housing or employment problems, planning
a budget, etc.) 0 1 2 3 4
h. Appointment reminders 0 1 2 3 4
i. Systematic client monitoring 0 1 2 3 4

(use of a periodic questionnaire or formal
monitoring tool to assess client progress)
j. Other – please describe __________________ 0 1 2 3 4
2. On average, how many clients per week do you see in individual psychotherapy?
__________
3. Which approach best describes your primary theoretical orientation?
a. Cognitive-behavioural
b. Family systems
c. Humanistic/experiential
d. Interpersonal
e. Psychodynamic
f. Other (please specify) _______________
4. How many years have you been in independent practice?

a. Currently in supervised practice
b. _____ years in autonomous practice
5. What is your gender?

a. Male
b. Female
6. What is your age

_________
7. What is your highest achieved professional degree

a. Doctorate
b. Masters
8. Approximately what percentage of your services are provided to :

a. Adults ______
b. Children ______
Adolescents ______
Appendix P: Examination of Therapist Effects in Study 2
Given that Study 2 had been published, no changes to it are possible. However, in
light of research findings that approximately 8% of the variability in treatment outcomes
can be attributable to therapists (Kim, Wampold, & Bolt, 2006), researchers increasingly
use hierarchical linear modeling with therapist included as a random factor so that
variability among therapists is accounted for in the model when testing for significant
differences between clients. Significant variability attributable to therapists, i.e.,
dependence in the therapist data, violates assumptions of parametric tests and can result
in incorrect estimation of error terms and an inflated risk of Type I error (Crits-Cristoph
& Mintz, 1991).
I conducted a post hoc analysis of therapist effects in Study 2 using HLM 7
software. I examined the variability in each dependent variable accounted for by
therapists using procedures described in Kim et al. (2006). The proportion of variance
resulting from therapists is the intraclass correlation coefficient, !I, defined as the ratio of
variance attributable to therapist "20 to the total variance, which is the sum of the therapist
variance and error variance #2 so that:
!I = "20/ "20 + #2
Table 8 contains intraclass correlation coefficients (!I) for each dependent
variable in the analyses. Kenny, Kashy, and Bolger (1998), pp.238, have calculated the
probability of making a type I error for nested designs as a function of !I, group size
(clients per therapist; M = 3.3), and total sample size (number of therapists; 31). I used
Kenny et al’s formula = .05/ (new probability of making a Type I error/.05) = .036 to
adjust the Type I error rate to account for inflation caused by dependence in the
therapists’ data. See Table 8 for adjusted I-values for each dependent variable. The mean
therapist !I was .09. Based on their calculations, the actual probability given an average
therapist !I of .09 is p = .07. Given that the Bonferroni correction was applied in Study 2
(10 reasons for termination for each analysis, thus the familywise alpha was divided by
10), the adjusted Bonferroni correction produced an adjusted $ of .004 for pairwise
comparisons. Using this adjusted p-value does not change interpretation of results from
Study 2. Furthermore, the Bonferroni correction is exceptionally conservative with
increasing comparisons, and an acceptable familywise alpha for multiple comparisons
can be as high as .15 (Tabachnick & Fidell, 2007). I used a familywise alpha of .05 in the
first place, taking a conservative approach to Type I error. Therefore, I feel confident that
the results from Study 2 hold despite dependence caused by therapist effects in the data.
Table 8
Therapist Effects (Intraclass Correlation Coefficient, !I) and Adjusted Type I Error Rate
(p-value) for Each Dependent Variable
!I Adjusted
Dependent Variable Type I error
Client: Accomplished goals .07 .04

Client: Could no longer fit time for therapy into schedule .15 .03
Client: Just lost interest in therapy .22 .02
Client: No longer had money or insurance coverage .00 .05
Client: Felt therapy was going nowhere so ended therapy .22 .02
Client: Felt therapy was making things worse .24 .02
Client: Weren’t confident in therapist’s ability to help .17 .03
Client: Uncomfortable talking about personal matters .14 .03
Client: Therapy did not fit with ideas of what would be helpful .17 .03
Client: Decided to go elsewhere for services .00 .05
Therapist: Accomplished goals .06 .04
Therapist: Could no longer fit time for therapy into schedule .00 .05
Therapist: Just lost interest in therapy .08 .03
Therapist: No longer had money or insurance coverage .00 .05
Therapist: Felt therapy was going nowhere so ended therapy .21 .03
Therapist: Felt therapy was making things worse .10 .03
Therapist: Weren’t confident in therapist’s ability to help .00 .05
Therapist: Uncomfortable talking about personal matters .21 .03
Therapist: Therapy did not fit with ideas of what would be helpful .04 .04
Therapist: Decided to go elsewhere for services .00 .05
Difference score 1 .00 .05
Working Alliance Inventory total score client .00 .05
Working Alliance Inventory total score therapist .09 .04
Barriers to Participation in Treatment Scale total score client .23 .02
Barriers to Participation in Treatment Scale total score therapist .04 .05
SCL-10 pretest .01 .05
SCL-10 posttest .00 .05
Note. Difference score = (client score – therapist score for the importance of each
termination reason)

Razones para Terminar La Terapia PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Razones para Terminar La Terapia PDF

Uploaded by

Copyright:

Available Formats

REASONS FOR TERMINATING PSYCHOTHERAPY: CLIENT AND THERAPIST

Dissertation submitted to the

Faculty of Graduate and Postdoctoral Studies

in partial fulfillment of the requirements for the degree of

© Robin Westmacott, Ottawa, Canada, 2011

395 Wellington Street 395, rue Wellington

Our file Notre référence

The author retains copyright L'auteur conserve la propriété du droit d'auteur

In compliance with the Canadian Conformément à la loi canadienne sur la

perspectives of reasons for termination, working alliance, and barriers to treatment

unilateral termination. In Study 1, 43.1 percent of respondents reported terminating therapy

therapists. In Study 3 psychologists assigned differential importance to reasons for

terms of research and clinical implications.

Perspectives on Therapy Termination and the Use of Therapy Engagement Strategies”

related to termination from psychotherapy: A comparison between unilateral and mutual

study hypotheses, and editing of manuscripts.

encouraging and modeling a sustainable approach to work-life balance. My committee

Westra, facilitated a stimulating, productive, and enjoyable learning experience throughout

the defense process and deserve many thanks.

Statement of Co-Authorship ....................................................................................................iv

List of Tables.......................................................................................................................... xii

Reasons for Terminating Psychotherapy: Client and Therapist Perspectives...........................1

Prevalence of Premature Termination...................................................................................1

Correlates of Unilateral Termination ....................................................................................3

Client Expectations ...............................................................................................................5

Client Reasons for Termination ............................................................................................7

Working Alliance ..................................................................................................................9

Barriers to Treatment Participation .....................................................................................12

Concordance between Client and Therapist Perspectives on Termination .........................13

Reasons for Early versus Later Unilateral Termination......................................................18

Therapist Use of Engagement Strategies in Routine Practice: Impact of Theoretical

Overview of Studies and Hypotheses .................................................................................32

Reasons for Terminating Psychotherapy: A General Population Study .................................37

The Present Study ...............................................................................................................42

Participants and Procedure ..................................................................................................43

Reasons for Termination: Self-Reported Reasons for Termination....................................47

Odds of Selecting Reasons for Termination According to Demographic Variables, Mental

Disorder Diagnoses, and Mental Health Care Provider ......................................................48

Client and Therapist Views of Contextual Factors Related to Termination from

A Comparison between Unilateral and Mutual Terminators ..................................................65

Reasons for Termination .....................................................................................................69

Therapeutic Alliance ...........................................................................................................72

Barriers to Treatment Participation .....................................................................................73

The Present Study and Hypotheses .....................................................................................74

Preliminary Analyses ..........................................................................................................82

Mutual vs. Unilateral Terminators: Reasons for Termination. Hypothesis 1a ...................84

Hypotheses 1b and 2b .........................................................................................................88

Congruence Between Client and Therapist Views on Barriers to Treatment Participation.

Hypotheses 1c and 2c..........................................................................................................88

Psychologists’ Perspectives on Therapy Termination and the Use of Therapy Engagement

Reasons for Early versus Later Unilateral Termination May Differ.................................111

Therapists Perspectives of Client Reasons for Termination .............................................112

Therapist Behaviors that Foster Mutual Decisions to End Psychotherapy .......................115

The Present Study and Hypotheses ...................................................................................116

Proportions of Clients who Terminated at Different Points in Therapy ...........................123

Perspectives of Reasons for Termination Within Client Groups ......................................124

Psychologists’ Use of Engagement Strategies ..................................................................125

Perspectives of Reasons for Termination (Hypotheses 1 and 2).......................................126

Perspectives of Reasons for Termination: Impact of Theoretical Orientation (Hypothesis

Theoretical Orientation and Use of Engagement Strategies (Hypothesis 4).....................129

Psychologists Perspectives of Clients’ Reasons for Termination .....................................131

Theoretical Orientation .....................................................................................................134

Use of Engagement Strategies ..........................................................................................134